Provider Demographics
NPI:1992116495
Name:BROXTON, TONY L
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:L
Last Name:BROXTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N FREDERICK AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-3400
Mailing Address - Country:US
Mailing Address - Phone:386-255-5569
Mailing Address - Fax:386-255-5277
Practice Address - Street 1:240 N FREDERICK AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3400
Practice Address - Country:US
Practice Address - Phone:386-255-5569
Practice Address - Fax:386-255-5277
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010793800OtherPROVIDER MEDICAID NUMBER