Provider Demographics
NPI:1154372241
Name:IDC OF VOLUSIA, LLC
Entity type:Organization
Organization Name:IDC OF VOLUSIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:REBA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISAAC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-410-4981
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32170-0070
Mailing Address - Country:US
Mailing Address - Phone:386-410-4981
Mailing Address - Fax:386-410-4982
Practice Address - Street 1:410 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7323
Practice Address - Country:US
Practice Address - Phone:386-410-4981
Practice Address - Fax:386-410-4982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89116207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX ID