Provider Demographics
NPI:1750374120
Name:RHODES, JAN RICHARD (MD)
Entity type:Individual
Prefix:MR
First Name:JAN
Middle Name:RICHARD
Last Name:RHODES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 DUNLAWTON AVE
Mailing Address - Street 2:STE 1A
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127
Mailing Address - Country:US
Mailing Address - Phone:386-760-5008
Mailing Address - Fax:386-760-0084
Practice Address - Street 1:1400 DUNLAWTON AVE
Practice Address - Street 2:STE 1A
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127
Practice Address - Country:US
Practice Address - Phone:386-760-5008
Practice Address - Fax:386-760-0084
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044566208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106797500Medicaid
FL94523YMedicare PIN