Provider Demographics
NPI:1902855596
Name:WEBB, ETHAN ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:ALAN
Last Name:WEBB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:805 CENTURY MEDICAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2100
Mailing Address - Country:US
Mailing Address - Phone:321-268-6264
Mailing Address - Fax:321-267-2713
Practice Address - Street 1:250 HARRISON ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-5026
Practice Address - Country:US
Practice Address - Phone:321-267-1424
Practice Address - Fax:321-267-2713
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME119885207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL011682100Medicaid
FLHW603ZMedicare PIN
LA731669340OtherTAX ID#
LAG69285Medicare UPIN