1578687117 NPI number — ELIZABETH A FORMY-DUVAL OT

Table of content: ELIZABETH A FORMY-DUVAL OT (NPI 1578687117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578687117 NPI number — ELIZABETH A FORMY-DUVAL OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORMY-DUVAL
Provider First Name:
ELIZABETH
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578687117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5831 BEE RIDGE RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34233-5090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-782-0102
Provider Business Mailing Address Fax Number:
941-794-1863

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5831 BEE RIDGE RD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SARASOTA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34233-5090
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-378-5100
Provider Business Practice Location Address Fax Number:
941-960-1962
Provider Enumeration Date:
03/19/2007

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: 225X00000X , with the licence number:  OT6623 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XH1200X , with the licence number: OT6623 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: OT6623 . This is a "STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".