MEDICARE: DR. DONALD ROY PAKE JR.

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	103T00000X	Psychologist	PY7612	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	:	1417140542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD ROY PAKE JR.

Provider Business Mailing Address
First Line	:	429 S TYNDALL PKWY STE B
Second Line	:
City	:	CALLAWAY
State	:	FL
Zip	:	32404-6746
Country	:	US
Telephone Number	:	850-541-3504
Fax Number	:	850-785-6700

Provider Business Practice Location Address
First Line	:	429 S TYNDALL PKWY STE B
Second Line	:
City	:	CALLAWAY
State	:	FL
Zip	:	32404-6746
Country	:	US
Telephone Number	:	850-541-3504
Fax Number	:	850-785-6700

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

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	07/27/2022

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