MEDICARE: NWE OO 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	2084P0800X	Psychiatry Physician	MD067262L	PA
2	2084P0800X	Psychiatry Physician	ME118929	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306962956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NWE OO M.D.

Provider Business Mailing Address
First Line	:	700 8TH AVE W STE 101
Second Line	:
City	:	PALMETTO
State	:	FL
Zip	:	34221-4737
Country	:	US
Telephone Number	:	941-776-4000
Fax Number	:	941-845-4963

Provider Business Practice Location Address
First Line	:	43 BARKLEY CIR STE 201
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-7518
Country	:	US
Telephone Number	:	407-620-8775
Fax Number	:

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	12/19/2017

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