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Provider Information for 1942658174

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: 1942658174

Calendar   Last Updated:  2018-09-12
  Certification Date: 


Name Value
NPI 1942658174
Enumeration Date 2016-05-27
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 14690 SPRING HILL DR STE 305
SPRING HILL, FL 34609-8102
United States

Phone: 352-277-5348 | Fax: 352-606-2857
View Map External Link
Primary Practice Address 445 MARINER BLVD
SPRING HILL, FL 34609-5680
United States

Phone: 352-666-1200 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Other DEA FL FL5976228
MEDICAID FL 017636500
Other ME LICENSE FL ME128127
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL ME 128127