Provider Demographics
NPI:1043261415
Name:MEDICAL VENTURES OF AMERICA
Entity type:Organization
Organization Name:MEDICAL VENTURES OF AMERICA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-750-5501
Mailing Address - Street 1:PO BOX 1746
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32158-1746
Mailing Address - Country:US
Mailing Address - Phone:352-750-5501
Mailing Address - Fax:352-750-5029
Practice Address - Street 1:8404 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-4016
Practice Address - Country:US
Practice Address - Phone:352-351-8881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34537OtherBLS PROV NUMBER
FLB902BOtherBLUE SHIELD PROVIDER #
FLDA0366Medicare ID - Type UnspecifiedRR MEDICARE PROV NUMBER
FLB902BOtherBLUE SHIELD PROVIDER #