1467454330 NPI number — ROBERT LAKE PURDON M.D.

Table of content: ROBERT LAKE PURDON M.D. (NPI 1467454330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467454330 NPI number — ROBERT LAKE PURDON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PURDON
Provider First Name:
ROBERT
Provider Middle Name:
LAKE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1467454330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 SE 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34471-4118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-861-0440
Provider Business Mailing Address Fax Number:
352-861-1869

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1540 CLEMENTE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE VILLAGES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159-8960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-259-2200
Provider Business Practice Location Address Fax Number:
352-259-2203
Provider Enumeration Date:
08/11/2005

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: 2085R0001X , with the licence number:  ME43489 , 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: 35205U . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 068969600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: ME43489 . This is a "MEDICAL LIC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 068969600 . 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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