1720247869 NPI number — MIDLAND FLORIDA INFECTIOUS DISEASES SPECIALISTS PL

Table of content: (NPI 1720247869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720247869 NPI number — MIDLAND FLORIDA INFECTIOUS DISEASES SPECIALISTS PL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDLAND FLORIDA INFECTIOUS DISEASES SPECIALISTS PL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1720247869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 471027
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MONROE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32747-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-228-0661
Provider Business Mailing Address Fax Number:
386-228-0662

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
955 TOWN CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ORANGE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32763-8255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-228-0661
Provider Business Practice Location Address Fax Number:
386-228-0662
Provider Enumeration Date:
06/04/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OGUCHI
Authorized Official First Name:
GODSON
Authorized Official Middle Name:
I
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-228-0661

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  ME89341 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000414800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".