Healthcare Provider Details

I. General information

NPI: 1215119193
Provider Name (Legal Business Name): CANTONMENT FAMILY MEDICINE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S. HWY 29
CANTONMENT FL
32533
US

IV. Provider business mailing address

PO BOX 553
CANTONMENT FL
32533-0553
US

V. Phone/Fax

Practice location:
  • Phone: 850-476-0559
  • Fax: 850-476-0599
Mailing address:
  • Phone: 850-476-0559
  • Fax: 850-476-0599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME73208
License Number StateFL

VIII. Authorized Official

Name: DONNA S. JUDSON
Title or Position: PRESIDENT/OWNER
Credential: MD
Phone: 850-476-0559