Provider Demographics
NPI:1720037211
Name:VOLUSIA OB GYN
Entity Type:Organization
Organization Name:VOLUSIA OB GYN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBONARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-252-5858
Mailing Address - Street 1:500 HEALTH BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1492
Mailing Address - Country:US
Mailing Address - Phone:386-252-5858
Mailing Address - Fax:386-252-4477
Practice Address - Street 1:500 HEALTH BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1492
Practice Address - Country:US
Practice Address - Phone:386-252-5858
Practice Address - Fax:386-252-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45453OtherBCBS
FLK1182Medicare ID - Type Unspecified