Provider Demographics
NPI:1588998488
Name:VILLAGE FAMILY PRACTICE
Entity type:Organization
Organization Name:VILLAGE FAMILY PRACTICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAGOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-544-2500
Mailing Address - Street 1:8250 BRYAN DAIRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33777-1356
Mailing Address - Country:US
Mailing Address - Phone:727-544-2500
Mailing Address - Fax:727-541-6165
Practice Address - Street 1:8250 BRYAN DAIRY RD STE 300
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33777-1356
Practice Address - Country:US
Practice Address - Phone:727-544-7908
Practice Address - Fax:727-541-6165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S0006179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80557Medicare PIN
FLE39856Medicare UPIN