Provider Demographics
NPI:1255479218
Name:WEST FLORIDA MEDICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:WEST FLORIDA MEDICAL ASSOCIATES, PA
Other - Org Name:SUNCOAST PRIMARY CARE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLACASTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-341-5520
Mailing Address - Street 1:PO BOX 640573
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34464-0573
Mailing Address - Country:US
Mailing Address - Phone:352-746-1558
Mailing Address - Fax:352-746-3838
Practice Address - Street 1:3733 E GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3206
Practice Address - Country:US
Practice Address - Phone:352-465-8001
Practice Address - Fax:352-465-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071085261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32745OtherBCBS OF FLORIDA
FL660075101Medicaid
FL32745OtherBCBS OF FLORIDA