Healthcare Provider Details

I. General information

NPI: 1124136155
Provider Name (Legal Business Name): RICHARD B ALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4632 S 25TH ST
FORT PIERCE FL
34981-5057
US

IV. Provider business mailing address

4632 S 25TH ST
FORT PIERCE FL
34981-5057
US

V. Phone/Fax

Practice location:
  • Phone: 772-464-9595
  • Fax: 772-464-9582
Mailing address:
  • Phone: 772-464-9595
  • Fax: 772-464-9582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberME33479
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: