=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730239575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILLIP D.DECUBELLIS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2007
-----------------------------------------------------
Last Update Date | 01/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2828 E COMMERCIAL BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-776-5700
-----------------------------------------------------
Fax | 954-776-5701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2828 E COMMERCIAL BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-776-5700
-----------------------------------------------------
Fax | 954-776-5701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIC
-----------------------------------------------------
Name | PHILLIP D DECUBELLIS
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 954-776-5700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------