Healthcare Provider Details

I. General information

NPI: 1285831743
Provider Name (Legal Business Name): ANTHONY JOSEPH ALLOTTA III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5005 PORT ST JOHN PKWY # 2100 PARRISH MEDICAL GROUP
PORT ST JOHN FL
32927-4305
US

IV. Provider business mailing address

805 CENTURY MEDICAL DR SUITE C
TITUSVILLE FL
32796-2100
US

V. Phone/Fax

Practice location:
  • Phone: 321-433-2247
  • Fax: 321-635-9310
Mailing address:
  • Phone: 321-268-6264
  • Fax: 321-635-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS 10417
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: