MEDICARE: AJD MEDICAL INC

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	207RG0100X	Gastroenterology Physician	82935	FL

General Provider Information

NPI Number	:	1447595293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AJD MEDICAL INC

Provider Business Mailing Address
First Line	:	501 LIVE OAK ST
Second Line	:	SUITE B
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7312
Country	:	US
Telephone Number	:	386-427-0390
Fax Number	:	386-427-0394

Provider Business Practice Location Address
First Line	:	501 LIVE OAK ST
Second Line	:	SUITE B
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7312
Country	:	US
Telephone Number	:	386-427-0390
Fax Number	:	386-427-0394

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	ANTONIO DECARLI
Credential	:
Telephone Number	:	386-427-0390

Provider Enumeration Date	:	12/05/2012
Last Update Date	:	12/05/2012

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