Basic Information
| Provider Information | |||||||||
| NPI: | 1235273285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCARTHY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9671 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321209671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3866767130 | ||||||||
| FaxNumber: | 3866767125 | ||||||||
| Practice Location | |||||||||
| Address1: | 2777 ENTERPRISE RD | ||||||||
| Address2: | |||||||||
| City: | ORANGE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327638310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867742550 | ||||||||
| FaxNumber: | 3867750176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 06/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME121306 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014527100 | 05 | FL | MEDICAID | 1235273285 | 01 | FL | TRICARE | OTHER |