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General NPI Number Information
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NPI Number | 1942952536
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Entity Type | Individual
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Provider Name | DWAN SAMUEL THOMAS SR. MEDICAID PROVIDER
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Gender | Male
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Dates
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Enumeration Date | 01/25/2022
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Last Update Date | 01/25/2022
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Provider Practice Location Address
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Address Line | 2 REDWOOD TRCE
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City | OCALA
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State | FL
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Zip | 34472-6297
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Country | US
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Telephone | 352-433-8457
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Fax |
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Provider Business Mailing Address
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Address Line | 485 NW 45TH LN
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City | OCALA
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State | FL
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Zip | 34475-9546
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Country | US
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Telephone | 352-433-8457
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Fax |
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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 | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State |
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