Provider Demographics
NPI:1639271679
Name:NEEDHAM, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:NEEDHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDDIE
Other - Middle Name:
Other - Last Name:NEEDHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:133 BENMORE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4143
Mailing Address - Country:US
Mailing Address - Phone:407-646-7757
Mailing Address - Fax:407-646-7775
Practice Address - Street 1:133 BENMORE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4143
Practice Address - Country:US
Practice Address - Phone:407-646-7757
Practice Address - Fax:407-646-7775
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47498207Q00000X
FLME109868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003610000Medicaid
GAHO1628Medicare UPIN
FLFA053ZMedicare PIN