Basic Information
| Provider Information | |||||||||
| NPI: | 1184883134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POPA | ||||||||
| FirstName: | ILEANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502160100 | ||||||||
| FaxNumber: | 8502160101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323084646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8502160100 | ||||||||
| FaxNumber: | 8502160101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 02/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 060966 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME122340 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 898321912A | 05 | GA | MEDICAID | 014995800 | 05 | FL | MEDICAID |