Provider Demographics
NPI:1659825867
Name:ICTM
Entity Type:Organization
Organization Name:ICTM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:GOTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:301-466-9858
Mailing Address - Street 1:93 SW PALM COVE DR
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-4318
Mailing Address - Country:US
Mailing Address - Phone:301-466-9858
Mailing Address - Fax:
Practice Address - Street 1:93 SW PALM COVE DR
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-4318
Practice Address - Country:US
Practice Address - Phone:301-466-9858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00150042083T0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083T0002XAllopathic & Osteopathic PhysiciansPreventive MedicineMedical ToxicologyGroup - Single Specialty