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34498 Cortez Blvd Ridge Manor FL 33523-8908 | |
| (352) 583-4520 | |
| (352) 583-5527 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 34498 Cortez Blvd, Ridge Manor, Florida |
| Authorized Official Name and Position | Basim Ahmed (CHIEF OPERATING OFFICER) |
| Authorized Official Contact | 3525681988 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
34498 Cortez Blvd Ridge Manor FL 33523-8908 Ph: (352) 583-4520 | 34498 Cortez Blvd Ridge Manor FL 33523-8908 Ph: (352) 583-4520 |
| NPI Number | 1164568275 |
|---|---|
| Provider Enumeration Date | 01/29/2007 |
| Last Update Date | 01/27/2011 |
| Medicare PECOS PAC ID | 8426966854 |
|---|---|
| Medicare Enrollment ID | O20051118000564 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164568275 | NPI | - | NPPES |
| 38227A | Other | FL | BCBS |
| 255718500 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | ME0066026 (Florida) | Primary |
| Provider Name | Mark D. Bowden |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1669580668 PECOS PAC ID: 5698768711 Enrollment ID: I20040405001848 |
| Provider Name | Mahmud Ahmed |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1619976198 PECOS PAC ID: 9335057769 Enrollment ID: I20070507000474 |
| Provider Name | Juan P Lopez-gonzalez |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1225210685 PECOS PAC ID: 0749365716 Enrollment ID: I20190829001456 |
| Provider Name | Laura Gonzalez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1831742279 PECOS PAC ID: 5395172860 Enrollment ID: I20200221001442 |
| Provider Name | Brendalis Davila Rolon |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1538531975 PECOS PAC ID: 5193025252 Enrollment ID: I20220207000755 |
| Provider Name | Yamelky Castro Estivez |
|---|---|
| Provider Type | Practitioner - Certified Clinical Nurse Specialist (cns) |
| Provider Identifiers | NPI Number: 1861109415 PECOS PAC ID: 1052851904 Enrollment ID: I20240906001746 |