1790752699 NPI number — DR. BRIAN J DEONARINE MD

Table of content: DR. BRIAN J DEONARINE MD (NPI 1790752699)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790752699 NPI number — DR. BRIAN J DEONARINE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEONARINE
Provider First Name:
BRIAN
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
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:
1790752699
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1285 36TH STREET
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32960-6588
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-562-9923
Provider Business Mailing Address Fax Number:
877-635-0804

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1285 36TH STREET
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-6588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-562-9923
Provider Business Practice Location Address Fax Number:
877-635-0804
Provider Enumeration Date:
03/01/2006

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: 207RC0000X , with the licence number:  ME0072762 , 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: 10731790 . This is a "CAQH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 060055374 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 38042 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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