Provider Demographics
NPI:1417002809
Name:JONES, CANDICE WATTERS (MD)
Entity type:Individual
Prefix:DR
First Name:CANDICE
Middle Name:WATTERS
Last Name:JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 REGAL CREST DR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-3186
Mailing Address - Country:US
Mailing Address - Phone:407-878-4804
Mailing Address - Fax:
Practice Address - Street 1:1190 N STONE ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2511
Practice Address - Country:US
Practice Address - Phone:386-738-1792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP 21397208000000X
FLME109716208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004180200Medicaid
MDP 21397OtherUMP #