=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124136155
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD B ALLEN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 07/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4632 S 25TH ST
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34981-5057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-464-9595
-----------------------------------------------------
Fax | 772-464-9582
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4632 S 25TH ST
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34981-5057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-464-9595
-----------------------------------------------------
Fax | 772-464-9582
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0602X
-----------------------------------------------------
Taxonomy Name | Otolaryngic Allergy Physician
-----------------------------------------------------
License Number | ME33479
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------