1750374120 NPI number — MR. JAN RICHARD RHODES MD

Table of content: MR. JAN RICHARD RHODES MD (NPI 1750374120)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750374120 NPI number — MR. JAN RICHARD RHODES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RHODES
Provider First Name:
JAN
Provider Middle Name:
RICHARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1750374120
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 DUNLAWTON AVE
Provider Second Line Business Mailing Address:
STE 1A
Provider Business Mailing Address City Name:
PORT ORANGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-760-5008
Provider Business Mailing Address Fax Number:
386-760-0084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 DUNLAWTON AVE
Provider Second Line Business Practice Location Address:
STE 1A
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-760-5008
Provider Business Practice Location Address Fax Number:
386-760-0084
Provider Enumeration Date:
08/31/2005

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: 208600000X , with the licence number:  ME0044566 , 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: 106797500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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