Healthcare Provider Details

I. General information

NPI: 1225132251
Provider Name (Legal Business Name): NEIL STANLEY MEDALIE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 7TH TER SUITE #102
VERO BEACH FL
32960-6552
US

IV. Provider business mailing address

1710 36TH ST BLD A
VERO BEACH FL
32960-4824
US

V. Phone/Fax

Practice location:
  • Phone: 772-567-7088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberME 83624
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME 83624
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberME 83624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: