1912974585 NPI number — ERIC SARKIS MUDAFORT M.D.

Table of content: ERIC SARKIS MUDAFORT M.D. (NPI 1912974585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912974585 NPI number — ERIC SARKIS MUDAFORT M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUDAFORT
Provider First Name:
ERIC
Provider Middle Name:
SARKIS
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:
1912974585
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 474
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRA CEIA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34250-0474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-962-9791
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1020 34TH DR W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMETTO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34221-2553
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-962-9791
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2006

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: 207V00000X , with the licence number:  ME56921 , 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: P00017940 . This is a "RAILROAD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00448 . This is a "UNIVERSAL MEDICARE MASTERPIECE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 191910 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 836514 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10311 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 202561 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 260804900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P102210 . This is a "FREEDOM HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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