Healthcare Provider Details

I. General information

NPI: 1255583787
Provider Name (Legal Business Name): LAKE OKEECHOBEE DIGESTIVE DISEASE CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2008
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 SE PARK ST
OKEECHOBEE FL
34972-2967
US

IV. Provider business mailing address

9715 W BROWARD BLVD # 315
PLANTATION FL
33324-2351
US

V. Phone/Fax

Practice location:
  • Phone: 863-357-8222
  • Fax:
Mailing address:
  • Phone: 863-357-8222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID DUNCAN
Title or Position: BILLER
Credential:
Phone: 954-370-1053