Provider Demographics
NPI:1881223469
Name:GOKDENIZ, ETHEM
Entity Type:Individual
Prefix:
First Name:ETHEM
Middle Name:
Last Name:GOKDENIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2274 FAIRWAY VILLAS LN NORTH
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233
Mailing Address - Country:US
Mailing Address - Phone:479-414-9440
Mailing Address - Fax:
Practice Address - Street 1:2274 FAIRWAY VILLAS LN NORTH
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233
Practice Address - Country:US
Practice Address - Phone:479-414-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIVHM49347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle