MEDICARE: DR. JUDE DESORMEAU M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	ME64499	FL

General Provider Information

NPI Number	:	1720175383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUDE DESORMEAU M.D.

Provider Business Mailing Address
First Line	:	8927 HYPOLUXO RD
Second Line	:	SUITE A-4
City	:	LAKE WORTH
State	:	FL
Zip	:	33467-5262
Country	:	US
Telephone Number	:	772-871-7800
Fax Number	:	772-871-7822

Provider Business Practice Location Address
First Line	:	1860 N LAWNWOOD CIR
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-4828
Country	:	US
Telephone Number	:	772-871-7800
Fax Number	:	772-871-7822

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	09/21/2010

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