Healthcare Provider Details

I. General information

NPI: 1932730942
Provider Name (Legal Business Name): FREEPORT MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17256 MAIN ST N STE 1
BLOUNTSTOWN FL
32424-1775
US

IV. Provider business mailing address

PO BOX 1033
FREEPORT FL
32439-1033
US

V. Phone/Fax

Practice location:
  • Phone: 850-842-9912
  • Fax:
Mailing address:
  • Phone: 850-842-9912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RONALD GILBERT WATSON JR.
Title or Position: OWNER
Credential: APRN/CRNA
Phone: 850-842-9912