Provider Demographics
NPI:1902965684
Name:DITEODORO, LINDA ANN (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ANN
Last Name:DITEODORO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 BELFORT ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256
Mailing Address - Country:US
Mailing Address - Phone:904-398-3262
Mailing Address - Fax:904-265-4807
Practice Address - Street 1:4800 BELFORT ROAD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-398-7205
Practice Address - Fax:904-396-4047
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98832207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000085400Medicaid
FL000085400Medicaid