=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164526273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH COUNTY MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13838 US HIGHWAY 1
-----------------------------------------------------
City | SEBASTIAN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32958-3296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-581-6900
-----------------------------------------------------
Fax | 772-581-3395
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 220
-----------------------------------------------------
City | ROSELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32957-0220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-581-6900
-----------------------------------------------------
Fax | 772-581-3395
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. DAVID DEPUTRON
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 772-581-6900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------