Olympia Medical Group, LLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

OLYMPIA MEDICAL GROUP, LLC

Practice address

2306 North Blvd W Ste C
Davenport, FL 33837-8976

Phone

(863) 547-9200

NPI assigned

Feb 11, 2019

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Bala KodeNPI 1710590815

Title

Managing Partner

Phone

(863) 547-9200

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Lourdes Rebecca Rosario Lugo, MD

  • General Practice Physician
  • Kissimmee, FL
  • NPI 1346266301
  Medicare reassignment NPD
• Wolf Karl Von Waagner, MD

  • General Practice Physician
  • Davenport, FL
  • NPI 1124308580
  Medicare reassignment NPD
• Bala Kode, PHARMD

  • Pharmacist
  • Davenport, FL
  • NPI 1710590815
  NPD Authorized official
• Hernan III Lugo Olivieri, MEDICAL DOCTOR

  • General Practice Physician
  • Cabo Rojo, PR
  • NPI 1265491948

  FL

  Medicare reassignment
• Evelina Figueroa Nater, APRN

  • Family Nurse Practitioner
  • Lake Wales, FL
  • NPI 1689443293
  NPD (past)
• Mitzy Mattei Rivera, APRN

  • Family Nurse Practitioner
  • Haines City, FL
  • NPI 1174061618
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1549843200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1703203200000",
    "number": "1013473495",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2306 NORTH BLVD W STE C",
            "city": "DAVENPORT",
            "state": "FL",
            "postal_code": "338378976"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2306 NORTH BLVD W STE C",
            "city": "DAVENPORT",
            "state": "FL",
            "postal_code": "338378976",
            "telephone_number": "863-547-9200"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "OLYMPIA MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-02-11",
        "last_updated": "2023-12-22",
        "certification_date": "2023-12-22",
        "status": "A",
        "authorized_official_last_name": "KODE",
        "authorized_official_first_name": "BALA",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "863-547-9200"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "105446600",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLINIC LICENSE",
            "identifier": "HCC11921",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Cristabell M Ongay Vargas, PA

• Family Medicine Physician in Davenport, FL
• Providers in Davenport, FL by specialty
• Family Medicine Physician in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 22, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.