Healthcare Provider Details

I. General information

NPI: 1013944933
Provider Name (Legal Business Name): GEORGE RAYMOND IKELER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31450 CHURCH ST
SORRENTO FL
32776-9594
US

IV. Provider business mailing address

31450 CHURCH ST
SORRENTO FL
32776-9594
US

V. Phone/Fax

Practice location:
  • Phone: 352-735-4033
  • Fax: 352-735-2536
Mailing address:
  • Phone: 352-735-4044
  • Fax: 352-735-2536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME12314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: