Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | ME127760 | FL |
Y | 111NI0900X | Internist | ME127760 | FL |
N | 207RA0401X | Internist - Addiction Medicine | 034584 | GA |
N | 207RA0401X | Internist - Addiction Medicine | ME127760 | FL |
NPI | 1508819269 |
---|---|
Provider Name | Dr. James Lewis Fenley JR. |
First Address | Orange City, FL 32763-9129 |
Second Address | Orange City, FL 32763-9129 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2006 |
Last Update Date | 08/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
055002903A | (05) | GA |
11BDLZQ | MEDICARE UNSPEC (01) | GA |
D32072 | (02) | GA |