Provider Demographics
NPI:1740673300
Name:AFERMIN PRIMARY CARE PA
Entity type:Organization
Organization Name:AFERMIN PRIMARY CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:LARRAZABAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-334-1295
Mailing Address - Street 1:500 MEMORIAL CIR STE A
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5054
Mailing Address - Country:US
Mailing Address - Phone:386-334-1295
Mailing Address - Fax:
Practice Address - Street 1:2089 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2240
Practice Address - Country:US
Practice Address - Phone:386-767-7533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLETA MEDICAL CARE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-06
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0020477207Q00000X
FLME0086562207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069436300Medicaid
FL266766500Medicaid
FLH13844Medicare UPIN
FL64292ZMedicare PIN
FLD86172Medicare UPIN
FL57696ZMedicare PIN