Provider Demographics
NPI:1790034221
Name:MOFOR, JACK NANA (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:NANA
Last Name:MOFOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 W UNDERWOOD ST
Mailing Address - Street 2:MP 80
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2008
Mailing Address - Country:US
Mailing Address - Phone:888-912-3648
Mailing Address - Fax:321-841-4085
Practice Address - Street 1:86 W UNDERWOOD ST
Practice Address - Street 2:MP 80
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2008
Practice Address - Country:US
Practice Address - Phone:888-912-3648
Practice Address - Fax:321-841-4085
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113941207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME113941OtherMEDICAL LICENSE
FL006476400Medicaid
FLME113941OtherMEDICAL LICENSE