Healthcare Provider Details

I. General information

NPI: 1154953743
Provider Name (Legal Business Name): JOHN LOFTIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 MAR WALT DRIVE UNIT C
FORT WALTON BEACH FL
32547-6706
US

IV. Provider business mailing address

6954 ELLIOTS GIN LN
NAVARRE FL
32566-8587
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax: 877-413-5104
Mailing address:
  • Phone: 251-327-7026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9112927
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: