Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 207QA0505X | Family Medicine | Adult Medicine | 0101246967 | VIRGINIA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 1699836 | OTHER | FLORIDA | AETNA-HMO |
| 2 | 30454202 | OTHER | FLORIDA | CITRUS-PASADENA AVE S |
| 3 | 30454203 | OTHER | FLORIDA | CITRUS-WEST BAY |
| 4 | 48102 | OTHER | FLORIDA | BLUE CROSS BLUE SHEILD OF FLORIDA |
| 5 | 1063480 | OTHER | FLORIDA | CAREPLUS-49TH STREET |
| 6 | 269342900 | OTHER | FLORIDA | MEDIPASS |
| 7 | 4647936 | OTHER | FLORIDA | CIGNA |
| 8 | P103476 | OTHER | FLORIDA | FREEDOM HEALTH |
| 9 | PCP1591 | OTHER | FLORIDA | QUALITY HEALTH PLANS-49TH STREET |
| 10 | PCP1592 | OTHER | FLORIDA | QUALITY HEALTH PLANS-PASADENA |
| 11 | 269342900 | MEDICAID | FLORIDA | |
| 12 | 48102Y | MEDICARE PIN | | |
| 13 | $$$$$$$$$ | OTHER | FLORIDA | TRICARE |
| 14 | 201266825 | OTHER | FLORIDA | BEECH STREET |
| 15 | 01163123 | OTHER | FLORIDA | AMERIGROUP-MEDICARE |
| 16 | 7761591 | OTHER | MICRONESIA | AETNA |
| 17 | PCP1594 | OTHER | FLORIDA | QUALITY HEALTH PLANS-ICOT |
| 18 | 1063482 | OTHER | FLORIDA | CAREPLUS-WEST BAY |
| 19 | 30454201 | OTHER | FLORIDA | CITRUS-49TH STREET |
| 20 | 1063481 | OTHER | FLORIDA | CAREPLUS-PASADENA AVE S |
| 21 | 2442180 | OTHER | | UNITED HEALTH CARE |
| 22 | PCP1593 | OTHER | FLORIDA | QUALITY HEALTH PLANS-WEST BAY DR |
| 23 | 201266825 | OTHER | FLORIDA | AVALON |
| 24 | 292949 | OTHER | FLORIDA | AVMED |
| 25 | P00662865 | OTHER | FLORIDA | MEDICARE-RAILROAD |
