Provider Demographics
NPI:1407054166
Name:ALLERGY DIAGNOSTICS OF CENTRAL FL
Entity Type:Organization
Organization Name:ALLERGY DIAGNOSTICS OF CENTRAL FL
Other - Org Name:WEBSTER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WEBSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-775-7500
Mailing Address - Street 1:211 S VOLUSIA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-5839
Mailing Address - Country:US
Mailing Address - Phone:386-775-7500
Mailing Address - Fax:386-775-1904
Practice Address - Street 1:211 S VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-5839
Practice Address - Country:US
Practice Address - Phone:386-775-7500
Practice Address - Fax:386-775-1904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-04
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL059256100Medicaid
FL059256100Medicaid
FLD60591Medicare UPIN