Healthcare Provider Details

I. General information

NPI: 1689608846
Provider Name (Legal Business Name): FLORIDA PHLEBOLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 PALM BEACH LAKES BLVD SUITE 734
WEST PALM BEACH FL
33409-6503
US

IV. Provider business mailing address

1901 BUTTERFIELD RD SUITE 220
DOWNERS GROVE IL
60515-7915
US

V. Phone/Fax

Practice location:
  • Phone: 561-471-4050
  • Fax:
Mailing address:
  • Phone: 630-725-2730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: DAN DOMAN
Title or Position: PRESIDENT
Credential:
Phone: 630-725-2768