Healthcare Provider Details

I. General information

NPI: 1144270240
Provider Name (Legal Business Name): OKALOOSA CARDIOLOGY P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E REDSTONE AVE SUITE A
CRESTVIEW FL
32539-5350
US

IV. Provider business mailing address

129 E REDSTONE AVE SUITE A
CRESTVIEW FL
32539-5350
US

V. Phone/Fax

Practice location:
  • Phone: 850-682-7212
  • Fax:
Mailing address:
  • Phone: 850-682-7212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DONNA M GIBSON
Title or Position: BILLING MANAGER
Credential:
Phone: 850-682-7212