Basic Information
| Provider Information | |||||||||
| NPI: | 1659370567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURRAY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 LAKE MIRIAM DR | ||||||||
| Address2: | STE S-1 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338132180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636472333 | ||||||||
| FaxNumber: | 8633931995 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 LAKE MIRIAM DR | ||||||||
| Address2: | STE S-1 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338132180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636472333 | ||||||||
| FaxNumber: | 8633931995 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0053067 | FL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 10201701 | 01 | FL | CITRUS HEALTHCARE | OTHER | 650140094001 | 01 | FL | TRICARE | OTHER | 07297 | 01 | FL | BC/BS | OTHER | 083957 | 01 | FL | CCN | OTHER | 12240 | 01 | FL | STAYWELL/HEALTHEASE | OTHER | 202095 | 01 | FL | AMERIGROUP | OTHER | PRO1162 | 01 | FL | QUALITY HEALTH PLAN | OTHER | 0305236 | 01 | FL | UNITED HEALTHCARE | OTHER | 1083957 | 01 | FL | AVMED | OTHER | 2111282 | 01 | FL | AETNA | OTHER |