Healthcare Provider Details

I. General information

NPI: 1679072375
Provider Name (Legal Business Name): SUNTREE ENDOCRINOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6619 N WICKHAM RD
MELBOURNE FL
32940-2006
US

IV. Provider business mailing address

6619 N WICKHAM RD
MELBOURNE FL
32940-2006
US

V. Phone/Fax

Practice location:
  • Phone: 321-259-9500
  • Fax: 321-253-1777
Mailing address:
  • Phone: 321-259-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME53320
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME81283
License Number StateFL

VIII. Authorized Official

Name: KELLY LUBY
Title or Position: BILLING MANAGER
Credential:
Phone: 321-259-9500