Provider Demographics
NPI:1124039409
Name:SUCH, ROMMELLE VON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROMMELLE
Middle Name:VON
Last Name:SUCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 FLORIDA PARK DR N
Mailing Address - Street 2:SUITE 109-110
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3852
Mailing Address - Country:US
Mailing Address - Phone:386-445-3619
Mailing Address - Fax:386-445-6925
Practice Address - Street 1:1 FLORIDA PARK DR N
Practice Address - Street 2:SUITE 109-110
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3852
Practice Address - Country:US
Practice Address - Phone:386-445-3619
Practice Address - Fax:386-445-6925
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0062070208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF74164Medicare UPIN