Provider Demographics
NPI:1053673145
Name:HUBBARD, EDDIE C
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:C
Last Name:HUBBARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7511 JOHN MATTHEWS RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-3401
Mailing Address - Country:US
Mailing Address - Phone:850-516-3039
Mailing Address - Fax:850-623-1181
Practice Address - Street 1:7511 JOHN MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-3401
Practice Address - Country:US
Practice Address - Phone:850-516-3039
Practice Address - Fax:850-623-1181
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA27456172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL673797879Medicaid