1265516611 NPI number — DANIEL ETTEDGUI, D.O. PA

Table of content: (NPI 1265516611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265516611 NPI number — DANIEL ETTEDGUI, D.O. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DANIEL ETTEDGUI, D.O. PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1265516611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1905 CLINT MOORE ROAD
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33496
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-912-9580
Provider Business Mailing Address Fax Number:
561-912-9506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 CLINT MOORE ROAD
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33496-2658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-912-9580
Provider Business Practice Location Address Fax Number:
561-912-9506
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCGINTY
Authorized Official First Name:
FLORI
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
561-912-9580

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  OS-6221 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2081P2900X , with the licence number: OS6221 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 114509600 . 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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