Healthcare Provider Details

I. General information

NPI: 1821466491
Provider Name (Legal Business Name): NORTHWEST FLORIDA ENT PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2015
Last Update Date: 04/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 RACETRACK RD NW STE 100
FORT WALTON BEACH FL
32547-1553
US

IV. Provider business mailing address

310 RACETRACK RD NW
FORT WALTON BEACH FL
32547-1553
US

V. Phone/Fax

Practice location:
  • Phone: 850-889-4550
  • Fax: 850-889-4549
Mailing address:
  • Phone: 850-889-4550
  • Fax: 850-807-5217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberME96773
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberME96773
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME96773
License Number StateFL

VIII. Authorized Official

Name: JASON REDWOOD BOOLE
Title or Position: PRESIDENT
Credential:
Phone: 850-889-4550