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General NPI Number Information
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NPI Number | 1992717417
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Entity Type | Individual
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Provider Name | JOLLY THOMAS M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/13/2006
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Last Update Date | 10/01/2018
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Provider Practice Location Address
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Address Line | 801 E. DIXIE AVENUE SUITE 101
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City | LEESBURG
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State | FL
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Zip | 34748
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Country | US
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Telephone | 352-326-4031
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Fax | 352-360-0257
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Provider Business Mailing Address
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Address Line | P.O. BOX 616788
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City | ORLANDO
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State | FL
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Zip | 32861-6788
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Country | US
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Telephone | 407-447-7105
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Fax | 407-770-0594
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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 Physician
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License Number | ME96580
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License Number State | FL
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