1598214926 NPI number — MONICA DELVISCIO DPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598214926 NPI number — MONICA DELVISCIO DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELVISCIO
Provider First Name:
MONICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DELIZO
Provider Other First Name:
MONICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598214926
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 SOUTHPARK BLVD STE B201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32086-5159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-824-1636
Provider Business Mailing Address Fax Number:
904-824-7488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
644 CESERY BLVD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32211-7165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-903-2755
Provider Business Practice Location Address Fax Number:
904-903-2756
Provider Enumeration Date:
09/27/2016

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: 225100000X , with the licence number:  PT34243 , 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: PT34243 . This is a "FL STATE LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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