Healthcare Provider Details

I. General information

NPI: 1376178277
Provider Name (Legal Business Name): BRIAN CEBALLOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4724 N DAVIS HWY STE 100
PENSACOLA FL
32503-2339
US

IV. Provider business mailing address

PO BOX 102222
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 850-201-2421
  • Fax: 850-886-2235
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberV5990
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME180109
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: