1770998478 NPI number — JORDAN PANICCO D.P.M.

Table of content: JORDAN PANICCO D.P.M. (NPI 1770998478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770998478 NPI number — JORDAN PANICCO D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANICCO
Provider First Name:
JORDAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1770998478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 8TH AVE W STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMETTO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34221-4737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-776-4008
Provider Business Mailing Address Fax Number:
941-845-4963

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 NURSING HOME DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34266-3839
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-993-2966
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/23/2014

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: 213ES0103X , with the licence number:  2024 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: 0116027378 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: PO4019 , 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: 2024 . This is a "NV MEDICAL LICENSE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 100768500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".