Healthcare Provider Details

I. General information

NPI: 1982165775
Provider Name (Legal Business Name): JASON D PHILIPPE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6450 38TH AVE N STE 300
SAINT PETERSBURG FL
33710-1649
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 727-655-9850
  • Fax: 276-559-8517
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME149618
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: