Provider Demographics
NPI:1790728947
Name:CANCER CARE OF NORTH FLORIDA PA
Entity Type:Organization
Organization Name:CANCER CARE OF NORTH FLORIDA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WASEEM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-755-1655
Mailing Address - Street 1:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-1642
Mailing Address - Country:US
Mailing Address - Phone:386-755-1655
Mailing Address - Fax:386-755-2330
Practice Address - Street 1:289 SW STONEGATE TER
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-3457
Practice Address - Country:US
Practice Address - Phone:386-755-1655
Practice Address - Fax:386-755-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276120300Medicaid
FL39239OtherBCBS
FLDE8930OtherRR MCR
FL39239OtherBCBS