Provider Demographics
NPI:1255583787
Name:LAKE OKEECHOBEE DIGESTIVE DISEASE CENTER PA
Entity type:Organization
Organization Name:LAKE OKEECHOBEE DIGESTIVE DISEASE CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-370-1053
Mailing Address - Street 1:9715 W BROWARD BLVD
Mailing Address - Street 2:# 315
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2351
Mailing Address - Country:US
Mailing Address - Phone:863-357-8222
Mailing Address - Fax:
Practice Address - Street 1:204 SE PARK ST
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-2967
Practice Address - Country:US
Practice Address - Phone:863-357-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-15
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBM717BMedicare PIN
FLBM717AMedicare PIN