Provider Demographics
NPI:1679813844
Name:GGB MD PA
Entity Type:Organization
Organization Name:GGB MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-776-1180
Mailing Address - Street 1:PO BOX 23158
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33307-3158
Mailing Address - Country:US
Mailing Address - Phone:954-776-1180
Mailing Address - Fax:954-776-1181
Practice Address - Street 1:935 INTRACOASTAL DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3623
Practice Address - Country:US
Practice Address - Phone:954-776-1180
Practice Address - Fax:954-776-1181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty