1316202401 NPI number — DR. DEDRIX BENJAMIN DAKA O.D.

Table of content: DR. DEDRIX BENJAMIN DAKA O.D. (NPI 1316202401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316202401 NPI number — DR. DEDRIX BENJAMIN DAKA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAKA
Provider First Name:
DEDRIX
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1316202401
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2017
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
Provider Second Line Business Mailing Address:
STE 101
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:
122 N BREVARD AVE
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:
34266-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-491-7585
Provider Business Practice Location Address Fax Number:
863-491-7588
Provider Enumeration Date:
07/05/2012

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: 152W00000X , with the licence number:  OPC4785 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152WL0500X , with the licence number: 0618002165 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 013849400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: H04587 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 013849400 . 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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