Healthcare Provider Details

I. General information

NPI: 1265477574
Provider Name (Legal Business Name): EMERALD COAST EAR, NOSE, THROAT & ALLERGIES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 MAR WALT DR SUITE 100
FORT WALTON BEACH FL
32547-6645
US

IV. Provider business mailing address

1032 MAR WALT DR SUITE 100
FORT WALTON BEACH FL
32547-6645
US

V. Phone/Fax

Practice location:
  • Phone: 850-796-1368
  • Fax: 850-796-2368
Mailing address:
  • Phone: 850-796-1368
  • Fax: 850-796-2368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberME93776
License Number StateFL

VIII. Authorized Official

Name: DR. JOSEPH DANIEL SIEFKER
Title or Position: DOCTOR
Credential: MD
Phone: 850-796-1368