Basic Information
Provider Information | |||||||||
NPI: | 1639148331 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLAHERTY | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020 LAKE SUMTER LNDG | ||||||||
Address2: |   | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 321622699 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3526748905 | ||||||||
FaxNumber: | 3526748919 | ||||||||
Practice Location | |||||||||
Address1: | 2955 BROWNWOOD BLVD | ||||||||
Address2: |   | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 321632039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3526748700 | ||||||||
FaxNumber: | 3526748714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2006 | ||||||||
LastUpdateDate: | 12/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | 1014 | ME | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207VF0040X | OS12968 | FL | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery | 207VF0040X | 1014 | ME | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Female Pelvic Medicine and Reconstructive Surgery |
ID Information
ID | Type | State | Issuer | Description | 1040562 | 01 |   | AETNA | OTHER | 251470099 | 05 | ME |   | MEDICAID | 030420 | 01 |   | ANTHEM | OTHER |