Healthcare Provider Details

I. General information

NPI: 1699778027
Provider Name (Legal Business Name): JOHN C RUGGIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 E. PRIMA VISTA BLVD
PORT ST. LUCIE FL
34952-0000
US

IV. Provider business mailing address

782 E. PRIMA VISTA BLVD
PORT ST. LUCIE FL
34952-0000
US

V. Phone/Fax

Practice location:
  • Phone: 772-340-0923
  • Fax: 772-340-4462
Mailing address:
  • Phone: 772-340-0923
  • Fax: 772-340-4462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME67996
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME67996
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: