Healthcare Provider Details

I. General information

NPI: 1700191053
Provider Name (Legal Business Name): GERARD B AGBULOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST HRMC/HOSPITALIST PROGRAM
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

1223 GATEWAY DR
MELBOURNE FL
32901-2607
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1771
  • Fax: 321-434-1775
Mailing address:
  • Phone: 321-725-4500
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME107948
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberFL-ME107948-A
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number272573
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME107948
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: