1346471042 NPI number — JESSICA WHITE VIDEA DO

Table of content: JESSICA WHITE VIDEA DO (NPI 1346471042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346471042 NPI number — JESSICA WHITE VIDEA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE VIDEA
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITE
Provider Other First Name:
JESSICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346471042
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2855 N UNIVERSITY DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORAL SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33065-1404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-317-0772
Provider Business Mailing Address Fax Number:
954-317-0778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2855 N UNIVERSITY DR STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORAL SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33065-1404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-317-0772
Provider Business Practice Location Address Fax Number:
954-317-0778
Provider Enumeration Date:
07/30/2009

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:  OS12001 , 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: 009025300 . 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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