Healthcare Provider Details

I. General information

NPI: 1063975175
Provider Name (Legal Business Name): CARDIOVASCULAR CENTER OF AMERICA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 NW HALL OF FAME DR
LAKE CITY FL
32055-4833
US

IV. Provider business mailing address

575 N ROUTE 73 STE A6
WEST BERLIN NJ
08091-2440
US

V. Phone/Fax

Practice location:
  • Phone: 856-335-5025
  • Fax: 856-213-9269
Mailing address:
  • Phone: 856-335-5025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES O'DARE III
Title or Position: PRINCIPAL
Credential:
Phone: 856-335-5025