Provider Demographics
NPI:1235166778
Name:LARGE, JAMES W
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:LARGE
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 1:777 37TH ST
Mailing Address - Street 2:SUITE C105
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4873
Mailing Address - Country:US
Mailing Address - Phone:772-569-5094
Mailing Address - Fax:772-569-3816
Practice Address - Street 1:777 37TH ST
Practice Address - Street 2:SUITE C105
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4873
Practice Address - Country:US
Practice Address - Phone:772-569-5094
Practice Address - Fax:772-569-3816
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0039032174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL31135ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER
FLD54234Medicare UPIN