Healthcare Provider Details

I. General information

NPI: 1720175383
Provider Name (Legal Business Name): JUDE DESORMEAU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 N LAWNWOOD CIR
FORT PIERCE FL
34950-4828
US

IV. Provider business mailing address

8927 HYPOLUXO RD SUITE A-4
LAKE WORTH FL
33467-5262
US

V. Phone/Fax

Practice location:
  • Phone: 772-871-7800
  • Fax: 772-871-7822
Mailing address:
  • Phone: 772-871-7800
  • Fax: 772-871-7822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberME64499
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: