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General NPI Number Information
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NPI Number | 1912125451
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Entity Type | Individual
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Provider Name | Story Family Medicine
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Gender | Male
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Dates
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Enumeration Date | 04/22/2007
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Last Update Date | 07/22/2020
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Provider Practice Location Address
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Address Line | 17912 TOLEDO BLADE BLVD STE A
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City | PORT CHARLOTTE
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State | FL
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Zip | 339481021
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Country | US
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Telephone | 941-875-9059
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Fax | 941-206-2066
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Provider Business Mailing Address
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Address Line | 9048 FALCON CT
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City | VENICE
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State | FL
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Zip | 342937631
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Country | US
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Telephone | 941-875-9059
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Fax | 941-206-2066
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine
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License Number | ME106893
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License Number State | FL
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