Healthcare Provider Details

I. General information

NPI: 1073693313
Provider Name (Legal Business Name): OKAN ELIDEMIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5153 NORTH 9TH AVE. NEMOURS CHILDREN'S CLINIC
PENSACOLA FL
32504-8785
US

IV. Provider business mailing address

P.O. BOX 191 PROVIDER ENROLLMENT DEPARTMENT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 850-473-4516
  • Fax: 850-473-4516
Mailing address:
  • Phone: 302-651-5985
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number000612
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: