Provider Demographics
NPI:1508819269
Name:FENLEY, JAMES LEWIS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:LEWIS
Last Name:FENLEY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2583 S VOLUSIA AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-9129
Mailing Address - Country:US
Mailing Address - Phone:386-960-7830
Mailing Address - Fax:386-960-7833
Practice Address - Street 1:2583 S VOLUSIA AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-9129
Practice Address - Country:US
Practice Address - Phone:386-960-7830
Practice Address - Fax:386-960-7833
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127760207RA0401X, 207R00000X
GA034584207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055002903AMedicaid
GA11BDLZQOtherMEDICARE UNSPEC
GA055002903AMedicaid