Healthcare Provider Details

I. General information

NPI: 1659316941
Provider Name (Legal Business Name): D BADOLATO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N WICKHAM RD SUITE 101
MELBOURNE FL
32940-2028
US

IV. Provider business mailing address

6300 N WICKHAM RD SUITE 101
MELBOURNE FL
32940-2028
US

V. Phone/Fax

Practice location:
  • Phone: 321-253-2169
  • Fax: 321-253-1720
Mailing address:
  • Phone: 321-253-2169
  • Fax: 321-253-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID BADOLATO
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 321-253-2169