1528241700 NPI number — DR. LAILA BENZAKOUR NEEDHAM MD

Table of content: DR. LAILA BENZAKOUR NEEDHAM MD (NPI 1528241700)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528241700 NPI number — DR. LAILA BENZAKOUR NEEDHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NEEDHAM
Provider First Name:
LAILA
Provider Middle Name:
BENZAKOUR
Provider Name Prefix Text:
DR.
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:
NEEDHAM
Provider Other First Name:
LAILA
Provider Other Middle Name:
BENZAKOUR
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1528241700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 HEALTH PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 3002
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32086-3707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-819-1500
Provider Business Mailing Address Fax Number:
904-810-1023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 HEALTH PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE 3002
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32086-3707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-819-1500
Provider Business Practice Location Address Fax Number:
904-810-1023
Provider Enumeration Date:
12/11/2007

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: 207V00000X , with the licence number:  ME104699 , 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: 000947900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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