1942484688 NPI number — PHILIP M DEMOLA D.O.

Table of content: PHILIP M DEMOLA D.O. (NPI 1942484688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942484688 NPI number — PHILIP M DEMOLA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEMOLA
Provider First Name:
PHILIP
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
1942484688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7955 SPYGLASS HILL RD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32940-8249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-751-3389
Provider Business Mailing Address Fax Number:
321-775-1363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7955 SPYGLASS HILL RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-8249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-751-3389
Provider Business Practice Location Address Fax Number:
321-775-1363
Provider Enumeration Date:
12/17/2007

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: 208100000X , with the licence number:  BP10050541 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: OT012076 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: OS14694 , 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: OS14694 . This is a "FLORIDA MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 6470221 . This is a "UHC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: VE7HV . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 9356777 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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