Basic Information
Provider Information | |||||||||
NPI: | 1104098565 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GEORGE R IKELER MD PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SORENTO MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 31450 CHURCH STREET | ||||||||
Address2: |   | ||||||||
City: | SORRENTO | ||||||||
State: | FL | ||||||||
PostalCode: | 327769594 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527354044 | ||||||||
FaxNumber: | 3527352536 | ||||||||
Practice Location | |||||||||
Address1: | 31450 CHURCH STREET | ||||||||
Address2: |   | ||||||||
City: | SORRENTO | ||||||||
State: | FL | ||||||||
PostalCode: | 327769594 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527354044 | ||||||||
FaxNumber: | 3527352536 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2008 | ||||||||
LastUpdateDate: | 07/15/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IKELER | ||||||||
AuthorizedOfficialFirstName: | GEORGE | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3527354044 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | ME12314 | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.