Healthcare Provider Details

I. General information

NPI: 1558340240
Provider Name (Legal Business Name): ORTHOPAEDIC CLINIC OF DAYTONA BEACH PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 LPGA BLVD
DAYTONA BEACH FL
32117-7108
US

IV. Provider business mailing address

1865 LPGA BLVD
DAYTONA BEACH FL
32117-7108
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4596
  • Fax: 386-258-3561
Mailing address:
  • Phone: 386-255-4596
  • Fax: 386-258-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: ALBERT W. GILLESPY
Title or Position: PRESIDENT
Credential: MD
Phone: 386-255-4596