Healthcare Provider Details

I. General information

NPI: 1174596167
Provider Name (Legal Business Name): JOHN J BOMALASKI MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 SPYGLASS CT SUITE 300
MELBOURNE FL
32940-8288
US

IV. Provider business mailing address

PO BOX 560730
ROCKLEDGE FL
32956-0730
US

V. Phone/Fax

Practice location:
  • Phone: 321-752-0944
  • Fax: 321-752-0756
Mailing address:
  • Phone: 321-752-0944
  • Fax: 321-752-0756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN J BOMALASKI
Title or Position: OWNER
Credential: MD
Phone: 321-434-4656