Healthcare Provider Details

I. General information

NPI: 1427370469
Provider Name (Legal Business Name): MARTIN ANTONY FIDELIA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 MALABAR RD NE PHYSICIANS OFFICE BLDG #200
PALM BAY FL
32907-2576
US

IV. Provider business mailing address

1421 MALABAR RD NE PHYSICIANS OFFICE BLDG #200
PALM BAY FL
32907-2576
US

V. Phone/Fax

Practice location:
  • Phone: 321-308-2660
  • Fax: 321-984-9303
Mailing address:
  • Phone: 321-308-2660
  • Fax: 321-984-9303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105354
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: