Provider Demographics
NPI:1043402589
Name:FAMILY PHYSICIAN SERVICES INC
Entity Type:Organization
Organization Name:FAMILY PHYSICIAN SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:G
Authorized Official - Last Name:AYALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-368-7055
Mailing Address - Street 1:10278 BUENA VENTURA DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6766
Mailing Address - Country:US
Mailing Address - Phone:561-368-7055
Mailing Address - Fax:561-368-6599
Practice Address - Street 1:801 MEADOWS RD STE 111B
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2346
Practice Address - Country:US
Practice Address - Phone:561-368-7055
Practice Address - Fax:561-368-6599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83667207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAE914Medicare PIN