Provider Demographics
NPI:1013247550
Name:FLORIDA DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GWATHNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:850-875-7200
Mailing Address - Street 1:278 LASALLE LEFALL DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-5324
Mailing Address - Country:US
Mailing Address - Phone:850-875-7200
Mailing Address - Fax:850-875-7210
Practice Address - Street 1:278 LASALLE LEFALL DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-5324
Practice Address - Country:US
Practice Address - Phone:850-875-7200
Practice Address - Fax:850-875-7210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9169219172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty