Basic Information
| Provider Information | |||||||||
| NPI: | 1295777340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NILES | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10030 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321200030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862747800 | ||||||||
| FaxNumber: | 3862747801 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 W DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138704000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 08/03/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OS5288 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 044826500 | 05 | FL | MEDICAID | 80155 | 01 | FL | BLUE CROSS OF FLORIDA | OTHER | 207163 | 01 | FL | AMERIGROUP | OTHER |