Basic Information
| Provider Information | |||||||||
| NPI: | 1316970981 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YOUR GOOD HEALTH MEDICAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11000 PROSPERITY FARMS RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334103462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616224646 | ||||||||
| FaxNumber: | 5617758625 | ||||||||
| Practice Location | |||||||||
| Address1: | 11000 PROSPERITY FARMS RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334103462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616224646 | ||||||||
| FaxNumber: | 5617758625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 09/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | VASTOLA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5616224646 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS0003793 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | K9758 | 01 | FL | MEDICARE PTAN | OTHER |