Unknown Individual – Family Medicine Physician, NPI 1124280565

Family Medicine Physician

Unknown Individual is a healthcare provider. based in Port orange, Florida. specializing in Family Medicine Physician. They hold a License No. ME109035 (FL). The NPI Number for Unknown Individual is 1124280565

Main info

Organization

Inactive

22 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1124280565

Phone

(386) 231-6300

Address

5535 S WILLIAMSON BLVD

Deactivation Date

31 January 2024

Doctor Profile

Medical School Name

OTHER

Secondary Phone

3862316300

Graduation Year

2004 (22 years ago)

PAC ID

8022289131

Group Practice PAC ID

9739081142

Professional Enrollment ID

I20110921000798

Data current as of

20 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience14

Completeness75

Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

5535, South Williamson Boulevard, Port Orange, Volusia County, Florida, 32128, United States
SUITE 700
PORT ORANGE, FL 321288311
Phone: (386) 231-6300
Type: Mailing
PO BOX 612
NEW SMYRNA BEACH, FL 321700612
Phone: (386) 382-7177
Type: Mailing
3801 WOODBRIAR TRL
PORT ORANGE, FL 321299627
Phone: (386) 382-7177
Type: Location

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 32128)

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Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 9739081142View full group profile

Name	Specialty	State
NARGES MAZLOOM (D.O.)	O T O L A R Y N G O L O G Y	PA
LISA GONSALVES (M.D.)	-	FL
MARIA I LOPEZ (M.D.)	Cardiovascular Disease (Cardiology)	FL
KRISTINE MCGOWAN (ARNP)	-	FL
DR. ASTRID GRACE CLARKE (MD)	-	FL
DR. WILLIAM CAMPBELL III DOUGLASS (MD)	-	FL
ROBERT J MARTIN (M.D.)	-	FL
PRATHAP KUMAR SIMHADRI (MD)	Nephrology, Internal Medicine	FL
MRS. CAROL TANNER-ST. JAMES (M.D.)	Family Practice	FL
DR. UTPAL S DESAI (M.D.)	Vascular Surgery, Cardiac Surgery, Interventional Radiology, Thoracic Surgery	FL

Reviews

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Frequently asked questions

Can I verify Unknown Individual with an NPI only?

You can start verification with NPI 1124280565 for Unknown Individual, then check state licensing separately.

Why is Unknown Individual marked inactive in the NPI directory?

The public NPI listing for Unknown Individual is not currently active; confirm directly with the practice or licensing boards.

What taxonomy line describes Unknown Individual?

For research purposes, treat Unknown Individual as Family Medicine Physician in this dataset. Clinical services aligned with this taxonomy classification.

Does Unknown Individual list a practice location?

Patients near Port Orange, Florida may find Unknown Individual in results; validate coverage separately.

Why does Unknown Individual have multiple addresses?

4 practice locations appear in the available data. Multiple addresses are common for hospital privileges, telehealth, or multi-site groups.