Provider Demographics
NPI:1144270240
Name:OKALOOSA CARDIOLOGY P A
Entity type:Organization
Organization Name:OKALOOSA CARDIOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-682-7212
Mailing Address - Street 1:129 E REDSTONE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5350
Mailing Address - Country:US
Mailing Address - Phone:850-682-7212
Mailing Address - Fax:
Practice Address - Street 1:129 E REDSTONE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5350
Practice Address - Country:US
Practice Address - Phone:850-682-7212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258928100Medicaid
FL24136Medicare ID - Type UnspecifiedMEDICARE NUMBER