Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QG0300X | Family Doctor - Geriatric Medicine | ME0055332 | FL |
Y | 207R00000X | Internist | ME0055332 | FL |
Y | 111NI0900X | Internist | ME0055332 | FL |
NPI | 1265496251 |
---|---|
Provider Name | Christopher J Mavroides |
First Address | Okeechobee, FL 34972-1900 |
Second Address | Okeechobee, FL 34972-1900 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2006 |
Last Update Date | 19/08/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
061299501 | (05) | FL |
09288 | BLUE CROSS BLUE SHIELD (01) | FL |
110164184 | MEDICARE RAILROAD (01) | FL |
B74132 | (02) | FL |