Provider Demographics
NPI:1902175094
Name:SOMERS, JOHN P
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
Last Name:SOMERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W BROADWAY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9261
Mailing Address - Country:US
Mailing Address - Phone:407-366-7007
Mailing Address - Fax:
Practice Address - Street 1:1000 W BROADWAY ST STE 101
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9261
Practice Address - Country:US
Practice Address - Phone:407-366-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS38930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL032022600Medicaid