Healthcare Provider Details

I. General information

NPI: 1952637530
Provider Name (Legal Business Name): ELIZABETH M DAQUILA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 DUNLAWTON AVE STE 102
PORT ORANGE FL
32127-4234
US

IV. Provider business mailing address

851 DUNLAWTON AVE STE 102
PORT ORANGE FL
32127-4234
US

V. Phone/Fax

Practice location:
  • Phone: 386-402-7827
  • Fax: 386-410-5457
Mailing address:
  • Phone: 386-236-9328
  • Fax: 386-492-2586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.094470
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: