Provider Demographics
NPI:1336499540
Name:JOHN DEAGLE FAMILY PRACTICE
Entity Type:Organization
Organization Name:JOHN DEAGLE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:305-852-8208
Mailing Address - Street 1:90290 OVERSEAS HWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TAVERNIER
Mailing Address - State:FL
Mailing Address - Zip Code:33070-2263
Mailing Address - Country:US
Mailing Address - Phone:305-852-8208
Mailing Address - Fax:305-852-2616
Practice Address - Street 1:90290 OVERSEAS HWY
Practice Address - Street 2:SUITE 103
Practice Address - City:TAVERNIER
Practice Address - State:FL
Practice Address - Zip Code:33070-2263
Practice Address - Country:US
Practice Address - Phone:305-852-8208
Practice Address - Fax:305-852-2616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS06310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty