Provider Demographics
NPI:1629296587
Name:DRIFTWOOD FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:DRIFTWOOD FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:561-746-0208
Mailing Address - Street 1:2163 SOUTH US HWY #1
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33477-7338
Mailing Address - Country:US
Mailing Address - Phone:561-746-0208
Mailing Address - Fax:561-575-1267
Practice Address - Street 1:2163 SOUTH US HWY #1
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-7338
Practice Address - Country:US
Practice Address - Phone:561-746-0208
Practice Address - Fax:561-575-1267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0021189Medicare ID - Type Unspecified