Healthcare Provider Details

I. General information

NPI: 1124517289
Provider Name (Legal Business Name): JIDEOFOR EBONY OBODOZIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 06/09/2024
Certification Date: 06/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5167
US

IV. Provider business mailing address

901 STERTHAUS DR
ORMOND BEACH FL
32174-5133
US

V. Phone/Fax

Practice location:
  • Phone: 386-231-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2021048898
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberME165936
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: