Provider Demographics
NPI:1932730942
Name:FREEPORT MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:FREEPORT MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GILBERT
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:APRN/CRNA
Authorized Official - Phone:850-842-9912
Mailing Address - Street 1:PO BOX 1033
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439-1033
Mailing Address - Country:US
Mailing Address - Phone:850-842-9912
Mailing Address - Fax:
Practice Address - Street 1:17256 MAIN ST N STE 1
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1775
Practice Address - Country:US
Practice Address - Phone:850-842-9912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty