NPI |
1073513057 |
The first name of the authorized official. |
Entity Type Code |
1 |
The middle name of the authorized official. |
Provider Last Name Legal Name |
BAIZE-MOORE |
The last name of the provider. If the provider is an individual, this is the legal name. |
Provider First Name |
MARY |
The first name of the provider, if the provider
is an individual. |
Provider Middle Name |
JO |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Name Prefix Text |
DR. |
|
Provider Credential Text |
O.D. |
|
Provider First Line Business Practice Location Address |
8432 LOCKWOOD RIDGE RD |
|
Provider Business Practice Location Address City Name |
SARASOTA |
|
Provider Business Practice Location Address State Name |
FL |
|
Provider Business Practice Location Address Postal Code |
342432903 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
9413591105 |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Fax Number |
9413591229 |
The fax number associated with the location
address of the provider being identified. |
Provider Enumeration Date |
7/30/2005 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
6/28/2021 |
The date that a record was last updated or changed. |
Provider Gender Code |
F |
The code designating the provider’s gender if the provider is a person. |
Healthcare Provider Taxonomy Code 1 |
152W00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number 1 |
OPC 2467 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 1 |
FL |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
NPI Certification Date |
6/28/2021 |
|