Healthcare Provider Details

I. General information

NPI: 1205557691
Provider Name (Legal Business Name): LEWIS & KLANCKE CARDIOLOGY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 DUNLAWTON AVE STE 101
PORT ORANGE FL
32127-4252
US

IV. Provider business mailing address

695 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2321
US

V. Phone/Fax

Practice location:
  • Phone: 386-265-5926
  • Fax: 386-265-5928
Mailing address:
  • Phone: 386-258-8722
  • Fax: 386-258-9443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN T PHILLIPS
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 386-258-8722