1114952744 NPI number — ELIZABETH JUVENTA GOMAN MD

Table of content: DR. GAIL A FEDAK OD (NPI 1912037664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114952744 NPI number — ELIZABETH JUVENTA GOMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOMAN
Provider First Name:
ELIZABETH
Provider Middle Name:
JUVENTA
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:
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:
1114952744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 WOODMONT BLVD STE 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37205-5250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-315-5257
Provider Business Mailing Address Fax Number:
615-692-0547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4430 14TH ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34207-1425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-297-2123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2006

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: 207R00000X , with the licence number:  ME151986 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: N9860 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: L6Z09 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8852737 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 8CX150 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 284425001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112261800 . 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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