=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437369287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | J ROGER DEMONSTHENES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 W 5TH ST
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33805-4446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-293-3909
-----------------------------------------------------
Fax | 863-293-1909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 317 W 5TH ST
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33805-4446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-293-3909
-----------------------------------------------------
Fax | 863-293-1909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | J ROGER DEMOSTHENES
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 863-293-3909
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | ME0033791
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------