MEDICARE: JOHN RUSSELL LIVENGOOD M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME91299	FL

General Provider Information

NPI Number	:	1104911205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN RUSSELL LIVENGOOD M.D.

Provider Business Mailing Address
First Line	:	780 SW 24TH ST
Second Line	:	MEDICAL ADMINISTRATION
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33315-2643
Country	:	US
Telephone Number	:	954-467-4822
Fax Number	:

Provider Business Practice Location Address
First Line	:	780 SW 24TH ST
Second Line	:	MEDICAL ADMINISTRATION
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33315-2643
Country	:	US
Telephone Number	:	954-467-4822
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/08/2007

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