1174504484 NPI number — DR. KATIE E DRAKE D.O.

Table of content: DR. KATIE E DRAKE D.O. (NPI 1174504484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174504484 NPI number — DR. KATIE E DRAKE D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRAKE
Provider First Name:
KATIE
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174504484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SARASOTA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34277-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-202-5342
Provider Business Mailing Address Fax Number:
877-807-0253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 S FORT HARRISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33756-3908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-725-6170
Provider Business Practice Location Address Fax Number:
727-799-3511
Provider Enumeration Date:
11/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS9565 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16304 . This is a "BC/BS OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 016080000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 389141 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000013683G . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 016080000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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