Provider Demographics
NPI:1972834729
Name:RICHARD E. PROMIN, MD.PA
Entity Type:Organization
Organization Name:RICHARD E. PROMIN, MD.PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:PROMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-629-0181
Mailing Address - Street 1:3301 SW 34TH CIR STE 301
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-6615
Mailing Address - Country:US
Mailing Address - Phone:352-629-0181
Mailing Address - Fax:352-629-0587
Practice Address - Street 1:3301 SW 34TH CIR STE 301
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-6615
Practice Address - Country:US
Practice Address - Phone:352-629-0181
Practice Address - Fax:352-629-0587
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD E. PROMIN ,M.D.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME10123207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047439800Medicaid
FL047439800Medicaid
FLD59253Medicare UPIN