Healthcare Provider Details

I. General information

NPI: 1154372241
Provider Name (Legal Business Name): IDC OF VOLUSIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 PALMETTO ST
NEW SMYRNA BEACH FL
32168-7323
US

IV. Provider business mailing address

PO BOX 70
NEW SMYRNA BEACH FL
32170-0070
US

V. Phone/Fax

Practice location:
  • Phone: 386-410-4981
  • Fax: 386-410-4982
Mailing address:
  • Phone: 386-410-4981
  • Fax: 386-410-4982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberME89116
License Number StateFL

VIII. Authorized Official

Name: DR. REBA ISAAC
Title or Position: MD
Credential: MD
Phone: 386-410-4981