Healthcare Provider Details

I. General information

NPI: 1154702546
Provider Name (Legal Business Name): ALLYSON DEZIEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 UNIVERSITY BLVD STE 103
JUPITER FL
33458-2792
US

IV. Provider business mailing address

641 UNIVERSITY BLVD STE 103
JUPITER FL
33458-2792
US

V. Phone/Fax

Practice location:
  • Phone: 561-776-2830
  • Fax:
Mailing address:
  • Phone: 561-776-2830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number2015017599
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME147809
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME147809
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: