Basic Information
Provider Information | |||||||||
NPI: | 1215382023 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEAN | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | ALLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2147 | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339022147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2393437474 | ||||||||
FaxNumber: | 2393434185 | ||||||||
Practice Location | |||||||||
Address1: | 16230 SUMMERLIN RD STE 215 | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339085769 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2393437474 | ||||||||
FaxNumber: | 2393434185 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2016 | ||||||||
LastUpdateDate: | 08/05/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/05/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 2080P0206X | OS19040 | FL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 114724100 | 05 | FL |   | MEDICAID |