1093739906 NPI number — DR. CASEY PATRICK MD

Table of content: DR. CASEY PATRICK MD (NPI 1093739906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093739906 NPI number — DR. CASEY PATRICK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATRICK
Provider First Name:
CASEY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PATRICK
Provider Other First Name:
CASEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1093739906
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9430
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32120-9430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-274-7800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 W PLYMOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32720-3236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-209-4303
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2006

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: 207P00000X , with the licence number:  01060942A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: ME144799 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: N4655 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1093739906 . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1093739906 . This is a "TRICARE SOUTH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8L23788 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 208960901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 208960903 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105921400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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