Healthcare Provider Details

I. General information

NPI: 1639271679
Provider Name (Legal Business Name): JOHN EDWARD NEEDHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDDIE NEEDHAM M.D.

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 1ST ST S STE 100A
WINTER HAVEN FL
33880-3904
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 863-280-6080
  • Fax: 863-229-7587
Mailing address:
  • Phone: 727-281-9065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number47498
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME109868
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: