1710094784 NPI number — GABRIEL ANTHONY DECANDIDO MD

Table of content: GABRIEL ANTHONY DECANDIDO MD (NPI 1710094784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710094784 NPI number — GABRIEL ANTHONY DECANDIDO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DECANDIDO
Provider First Name:
GABRIEL
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1710094784
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2056
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33779-2056
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-536-0441
Provider Business Mailing Address Fax Number:
727-532-4861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8005 ULMERTON ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-536-0441
Provider Business Practice Location Address Fax Number:
727-532-4861
Provider Enumeration Date:
08/24/2006

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: 207Q00000X , with the licence number:  ME0039740 , 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: 62385 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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