Provider Demographics
NPI:1245244995
Name:CHURCHILL, JOHN ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALEXANDER
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15880 SUMMERLIN RD
Mailing Address - Street 2:STE 300 PMB 322
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-9612
Mailing Address - Country:US
Mailing Address - Phone:239-432-5100
Mailing Address - Fax:239-432-0629
Practice Address - Street 1:15821 HOLLYFERN CT
Practice Address - Street 2:
Practice Address - City:FT. MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-432-5100
Practice Address - Fax:239-432-0629
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME87100207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL221101OtherSTAYWELL HEALTHY KIDS
FL270843OtherAVMED
FL7566688-008OtherCIGNA
FL189182OtherAMERIGROUP
FL25519OtherBLUE CROSS BLUE SHIELD
FL4509387OtherAETNA
FL267883700Medicaid
FL7566688-008OtherCIGNA