=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053710152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EUGENE USBERGHI, JR., D.O.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2014
-----------------------------------------------------
Last Update Date | 08/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14651 PALM BEACH BLVD SUITE 100
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33905-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-694-5632
-----------------------------------------------------
Fax | 239-693-6202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14651 PALM BEACH BLVD SUITE 100
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33905-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-694-5632
-----------------------------------------------------
Fax | 239-693-6202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. EUGENE USBERGHI JR.
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 239-694-5632
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS0006042
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------