1003826272 NPI number — JO P DEAL MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003826272 NPI number — JO P DEAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEAL
Provider First Name:
JO
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
JO
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003826272
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8390 CHAMPIONS GATE BLVD
Provider Second Line Business Mailing Address:
SUITE 215
Provider Business Mailing Address City Name:
CHAMPIONS GATE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33896-8310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-390-1677
Provider Business Mailing Address Fax Number:
407-390-1765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
766 LAKELAND DR
Provider Second Line Business Practice Location Address:
A
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-368-3440
Provider Business Practice Location Address Fax Number:
601-368-3441
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  10460 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00018389 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01065367 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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