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Provider Information for 1154343002

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: 1154343002

Calendar   Last Updated:  2007-07-08
  Certification Date: 


Name Value
NPI 1154343002
Enumeration Date 2006-07-23
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 1964 HOWELL BRANCH RD SUITE 100
WINTER PARK, FL 32792-1042
United States

Phone: 407-681-2241 | Fax: 407-679-2779
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Primary Practice Address 3825 26TH ST W
BRADENTON, FL 34205-3507
United States

Phone: 941-755-8819 | Fax:
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Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 174400000X - Specialist FL ME61947