Healthcare Provider Details

I. General information

NPI: 1104911205
Provider Name (Legal Business Name): JOHN RUSSELL LIVENGOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 SW 24TH ST MEDICAL ADMINISTRATION
FORT LAUDERDALE FL
33315-2643
US

IV. Provider business mailing address

780 SW 24TH ST MEDICAL ADMINISTRATION
FORT LAUDERDALE FL
33315-2643
US

V. Phone/Fax

Practice location:
  • Phone: 954-467-4822
  • Fax:
Mailing address:
  • Phone: 954-467-4822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME91299
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: