Healthcare Provider Details

I. General information

NPI: 1043215643
Provider Name (Legal Business Name): DIGESTIVE HEALTH SPECIALISTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1070 N STONE ST STE D
DELAND FL
32720-0824
US

IV. Provider business mailing address

1070 N STONE ST STE D
DELAND FL
32720-0824
US

V. Phone/Fax

Practice location:
  • Phone: 386-822-9410
  • Fax: 386-469-0045
Mailing address:
  • Phone: 386-822-9410
  • Fax: 386-469-0045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME36213
License Number StateFL

VIII. Authorized Official

Name: MRS. FAITH Y TRADD
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 386-822-9410