Provider Demographics
NPI:1629195300
Name:FRUIT COVE FAMILY MEDICINE P A
Entity Type:Organization
Organization Name:FRUIT COVE FAMILY MEDICINE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-287-2794
Mailing Address - Street 1:1400 BISHOP ESTATES RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4244
Mailing Address - Country:US
Mailing Address - Phone:904-287-2794
Mailing Address - Fax:904-287-5362
Practice Address - Street 1:1400 BISHOP ESTATES RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32259-4244
Practice Address - Country:US
Practice Address - Phone:904-287-2794
Practice Address - Fax:904-287-5362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6601Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER