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Provider Information for 1134152044

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1134152044

Calendar   Last Updated:  2017-06-07
  Certification Date: 


Name Value
NPI 1134152044
Enumeration Date 2006-07-07
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 14690 SPRING HILL DR STE 101
SPRING HILL, FL 34609-8102
United States

Phone: #(352) 799-0046 | Fax: 352-606-2857
View Map External Link
Primary Practice Address 920 W JEFFERSON ST
BROOKSVILLE, FL 34601-2428
United States

Phone: 352-796-8824 | Fax: 352-796-7917
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Other BCBS 81835
MEDICAID FL 271521000
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL ME87400