Healthcare Provider Details

I. General information

NPI: 1780996918
Provider Name (Legal Business Name): JOHN EDWARD LOUDERMILK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4608 OPA LOCKA LN STE 300
DESTIN FL
32541-0745
US

IV. Provider business mailing address

4608 OPA LOCKA LN STE 300
DESTIN FL
32541-0745
US

V. Phone/Fax

Practice location:
  • Phone: 850-270-7141
  • Fax: 448-203-3818
Mailing address:
  • Phone: 850-270-7141
  • Fax: 448-203-3818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME147765
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01074589A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25027
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: