1689616674 NPI number — DR. EARL WAYNE FLORA PSYD

Table of content: SHANELL ALLEN (NPI 1215751870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689616674 NPI number — DR. EARL WAYNE FLORA PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLORA
Provider First Name:
EARL
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
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:
1689616674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 564
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23127-0564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-564-8522
Provider Business Mailing Address Fax Number:
757-566-0360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3305 POPLAR CREEK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23188-1058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-564-8522
Provider Business Practice Location Address Fax Number:
757-566-0360
Provider Enumeration Date:
06/12/2006

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: 103T00000X , with the licence number:  0810001797 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 031312 . This is a "VALUE OPTIONS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 095271 . This is a "BCBSVA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 86196 . This is a "SENTARA MENTAL HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 152183 . This is a "COMPSYCH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 244496 . This is a "MHN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 271332 . This is a "PHCS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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