Provider Demographics
NPI:1720247869
Name:MIDLAND FLORIDA INFECTIOUS DISEASES SPECIALISTS PL
Entity type:Organization
Organization Name:MIDLAND FLORIDA INFECTIOUS DISEASES SPECIALISTS PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GODSON
Authorized Official - Middle Name:I
Authorized Official - Last Name:OGUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-228-0661
Mailing Address - Street 1:PO BOX 471027
Mailing Address - Street 2:
Mailing Address - City:LAKE MONROE
Mailing Address - State:FL
Mailing Address - Zip Code:32747-1027
Mailing Address - Country:US
Mailing Address - Phone:386-228-0661
Mailing Address - Fax:386-228-0662
Practice Address - Street 1:955 TOWN CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8255
Practice Address - Country:US
Practice Address - Phone:386-228-0661
Practice Address - Fax:386-228-0662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89341207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000414800Medicaid