Provider Demographics
NPI: | 1619972387 |
---|---|
Name: | DEEM, ROBERT B (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ROBERT |
Middle Name: | B |
Last Name: | DEEM |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1549 S JEFFERSON |
Mailing Address - Street 2: | |
Mailing Address - City: | MONTICELLO |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32344-1651 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 850-997-0707 |
Mailing Address - Fax: | 850-997-6833 |
Practice Address - Street 1: | 1549 S JEFFERSON |
Practice Address - Street 2: | |
Practice Address - City: | MONTICELLO |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32344-1651 |
Practice Address - Country: | US |
Practice Address - Phone: | 850-997-0707 |
Practice Address - Fax: | 850-997-6833 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-06-17 |
Last Update Date: | 2015-04-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME0096771 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 10-3409 | Other | RURAL MEDICARE GROUP # |
FL | 276370200 | Medicaid | |
FL | 56525 | Other | BLUE CROSS BLUE SHIELD |
FL | 660037901 | Other | RURAL MEDICAID |
FL | AC462Z | Medicare PIN | |
FL | 10-3409 | Other | RURAL MEDICARE GROUP # |