Provider Demographics
NPI:1497750376
Name:DEPODESTA, CRAIG (DO)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:
Last Name:DEPODESTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33061-0132
Mailing Address - Country:US
Mailing Address - Phone:954-530-1600
Mailing Address - Fax:954-306-8234
Practice Address - Street 1:231B COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERDALE BY THE SEA
Practice Address - State:FL
Practice Address - Zip Code:33308-4441
Practice Address - Country:US
Practice Address - Phone:954-530-1600
Practice Address - Fax:954-306-8234
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261110400Medicaid
FL261110400Medicaid
FLH40017Medicare UPIN