Basic Information
Provider Information | |||||||||
NPI: | 1942250899 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEPARTMENT OF VETERAN'S AFFAIRS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 234 S WIMBROW DR | ||||||||
Address2: |   | ||||||||
City: | SEBASTIAN | ||||||||
State: | FL | ||||||||
PostalCode: | 329584538 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7723211000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2900 VETERANS WAY | ||||||||
Address2: |   | ||||||||
City: | VIERA | ||||||||
State: | FL | ||||||||
PostalCode: | 329408007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3216373788 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2006 | ||||||||
LastUpdateDate: | 07/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOWARD | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 3216373788 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | ARNP9217680 | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
No ID Information.