Provider Demographics
NPI:1104533173
Name:COLUMBIA FAMILY MEDICINE
Entity type:Organization
Organization Name:COLUMBIA FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-365-0809
Mailing Address - Street 1:238 SW CULLEN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WHITE
Mailing Address - State:FL
Mailing Address - Zip Code:32038-3536
Mailing Address - Country:US
Mailing Address - Phone:386-365-0809
Mailing Address - Fax:
Practice Address - Street 1:238 SW CULLEN AVE
Practice Address - Street 2:
Practice Address - City:FORT WHITE
Practice Address - State:FL
Practice Address - Zip Code:32038-3536
Practice Address - Country:US
Practice Address - Phone:386-497-1397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care