Provider Demographics
NPI:1316187156
Name:JOHN R PICKEN MD
Entity Type:Organization
Organization Name:JOHN R PICKEN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PICKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-552-8808
Mailing Address - Street 1:3530 FRUITVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:SARASOA
Mailing Address - State:FL
Mailing Address - Zip Code:34237
Mailing Address - Country:US
Mailing Address - Phone:941-552-8808
Mailing Address - Fax:941-552-8805
Practice Address - Street 1:3530 FRUITVILLE ROAD
Practice Address - Street 2:
Practice Address - City:SARASOA
Practice Address - State:FL
Practice Address - Zip Code:34237
Practice Address - Country:US
Practice Address - Phone:941-552-8808
Practice Address - Fax:941-552-8805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL58395AMedicare PIN