Healthcare Provider Details

I. General information

NPI: 1194728832
Provider Name (Legal Business Name): STEPHEN K BADOLATO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2005
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N WICKHAM RD STE 101 -108
MELBOURNE FL
32940-2028
US

IV. Provider business mailing address

247 LANSING ISLAND DR
INDIAN HARBOUR BEACH FL
32937-5102
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME78710
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: