Provider Demographics
NPI:1396837308
Name:INFECTIOUS DISEASES OF MID-FLORIDA, PA
Entity Type:Organization
Organization Name:INFECTIOUS DISEASES OF MID-FLORIDA, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:UKONU
Authorized Official - Middle Name:OKORO
Authorized Official - Last Name:EJIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-274-1966
Mailing Address - Street 1:104 LACOSTA LN STE 120
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-8160
Mailing Address - Country:US
Mailing Address - Phone:386-274-1966
Mailing Address - Fax:386-274-1964
Practice Address - Street 1:104 LACOSTA LN STE 120
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-8160
Practice Address - Country:US
Practice Address - Phone:386-274-1966
Practice Address - Fax:386-274-1964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86706207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266737100Medicaid
FL78720OtherBC OF FL
H78003Medicare UPIN