Basic Information
| Provider Information | |||||||||
| NPI: | 1285849141 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLOTTE COUNTY PRIMARY CARE PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 380639 | ||||||||
| Address2: | |||||||||
| City: | MURDOCK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339380639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416131700 | ||||||||
| FaxNumber: | 9412583370 | ||||||||
| Practice Location | |||||||||
| Address1: | 3067 TAMIAMI TRL | ||||||||
| Address2: | UNIT 3 | ||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339526601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416131700 | ||||||||
| FaxNumber: | 9412583370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 08/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9416131700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1215937735 | 01 | FL | NPI OTHER LOCATION | OTHER |