Provider Demographics
NPI:1386887230
Name:AJD MEDICAL LLC
Entity type:Organization
Organization Name:AJD MEDICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTONTIO
Authorized Official - Middle Name:J
Authorized Official - Last Name:DECARLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-423-5500
Mailing Address - Street 1:612 PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32168-7327
Mailing Address - Country:US
Mailing Address - Phone:386-423-5500
Mailing Address - Fax:386-409-9762
Practice Address - Street 1:612 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7327
Practice Address - Country:US
Practice Address - Phone:386-423-5500
Practice Address - Fax:386-409-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-08
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000749600Medicaid
FL000749600Medicaid