Basic Information
Provider Information | |||||||||
NPI: | 1407054166 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALLERGY DIAGNOSTICS OF CENTRAL FL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WEBSTER MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 211 S VOLUSIA AVE | ||||||||
Address2: |   | ||||||||
City: | ORANGE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 327635839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3867757500 | ||||||||
FaxNumber: | 3867751904 | ||||||||
Practice Location | |||||||||
Address1: | 211 S VOLUSIA AVE | ||||||||
Address2: |   | ||||||||
City: | ORANGE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 327635839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3867757500 | ||||||||
FaxNumber: | 3867751904 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/04/2007 | ||||||||
LastUpdateDate: | 11/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEBSTER | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3867757500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS0003567 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 059256100 | 05 | FL |   | MEDICAID |