Provider Demographics
NPI:1265844757
Name:FAMILY MEDICAL CARE OF MOUNT DORA INC
Entity type:Organization
Organization Name:FAMILY MEDICAL CARE OF MOUNT DORA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-834-7800
Mailing Address - Street 1:PO BOX 1844
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32756-1844
Mailing Address - Country:US
Mailing Address - Phone:352-383-8200
Mailing Address - Fax:
Practice Address - Street 1:17580 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6711
Practice Address - Country:US
Practice Address - Phone:352-383-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC10266207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty