1831594514 NPI number — COOLEY GEORGE PANTAZIS, MD PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831594514 NPI number — COOLEY GEORGE PANTAZIS, MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COOLEY GEORGE PANTAZIS, MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1831594514
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743170
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-622-1378
Provider Business Mailing Address Fax Number:
352-622-3672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 SW 1ST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-351-7262
Provider Business Practice Location Address Fax Number:
352-402-5047
Provider Enumeration Date:
10/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PANTAZIS
Authorized Official First Name:
COOLEY
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
352-208-7514

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  800000163 , 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: 013832900 . 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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