1306842240 NPI number — DR. REGINALD A ALLEN MD

Table of content: DR. REGINALD A ALLEN MD (NPI 1306842240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306842240 NPI number — DR. REGINALD A ALLEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALLEN
Provider First Name:
REGINALD
Provider Middle Name:
A
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:
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:
1306842240
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 90758
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33804-0758
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-566-9899
Provider Business Mailing Address Fax Number:
407-566-9893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 MAGNOLIA AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33880
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-293-6375
Provider Business Practice Location Address Fax Number:
863-293-8877
Provider Enumeration Date:
06/24/2005

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: 208800000X , with the licence number:  036069997 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: ME57508 , 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: 277900500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036069997 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112376400 . 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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