Basic Information
| Provider Information | |||||||||
| NPI: | 1174792048 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDFAST FAMILY PHYSICIANS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7970 N WICKHAM RD | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217517222 | ||||||||
| FaxNumber: | 3217516655 | ||||||||
| Practice Location | |||||||||
| Address1: | 7970 N WICKHAM RD | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217517222 | ||||||||
| FaxNumber: | 3217516655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3217517222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | OS4050 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.