1114366200 NPI number — DANIEL GOLOGORSKY MD, MBA

Table of content: DANIEL GOLOGORSKY MD, MBA (NPI 1114366200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114366200 NPI number — DANIEL GOLOGORSKY MD, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOLOGORSKY
Provider First Name:
DANIEL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD, MBA
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:
1114366200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 NW 49TH ST STE 125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33309-3750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-468-8072
Provider Business Mailing Address Fax Number:
954-468-8087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1625 SE 3RD AVE STE 501
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33316-2521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-468-8072
Provider Business Practice Location Address Fax Number:
954-468-8087
Provider Enumeration Date:
06/21/2013

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: 207WX0107X , with the licence number:  ME135746 , 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: 102175800 . 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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