1336147693 NPI number — MR. EARLE M PESCATORE JR. D.O.

Table of content: MR. EARLE M PESCATORE JR. D.O. (NPI 1336147693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336147693 NPI number — MR. EARLE M PESCATORE JR. D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PESCATORE
Provider First Name:
EARLE
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336147693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2021 E COMMERCIAL BLVD
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-3763
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-734-1298
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2021 E COMMERCIAL BLVD
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-3763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-734-1298
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  036102614 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X , with the licence number: OS11075 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101552 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036102614-2 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: IL0100 . This is a "JOHN DEERE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 10123243 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0369102614 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7648181 . This is a "AETNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com