Provider Demographics
NPI:1184132888
Name:FAMILY PRACTICE ON THE GO OF FLORIDA
Entity type:Organization
Organization Name:FAMILY PRACTICE ON THE GO OF FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HEISE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:888-808-0488
Mailing Address - Street 1:735 DUNLAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9226
Mailing Address - Country:US
Mailing Address - Phone:888-808-0488
Mailing Address - Fax:386-872-4232
Practice Address - Street 1:226 N NOVA RD STE 184
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5124
Practice Address - Country:US
Practice Address - Phone:888-808-0488
Practice Address - Fax:386-872-4232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-16
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83299207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty