Provider Demographics
NPI:1215119193
Name:CANTONMENT FAMILY MEDICINE PA
Entity type:Organization
Organization Name:CANTONMENT FAMILY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:S
Authorized Official - Last Name:JUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-476-0559
Mailing Address - Street 1:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-0553
Mailing Address - Country:US
Mailing Address - Phone:850-476-0559
Mailing Address - Fax:850-476-0599
Practice Address - Street 1:2400 S. HWY 29
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533
Practice Address - Country:US
Practice Address - Phone:850-476-0559
Practice Address - Fax:850-476-0599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253194100Medicaid
FL253194100Medicaid