Provider Demographics
NPI:1730239575
Name:PHILLIP D.DECUBELLIS PA
Entity type:Organization
Organization Name:PHILLIP D.DECUBELLIS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIC
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:D
Authorized Official - Last Name:DECUBELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-776-5700
Mailing Address - Street 1:2828 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4206
Mailing Address - Country:US
Mailing Address - Phone:954-776-5700
Mailing Address - Fax:954-776-5701
Practice Address - Street 1:2828 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4206
Practice Address - Country:US
Practice Address - Phone:954-776-5700
Practice Address - Fax:954-776-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390494600Medicaid
FLK1117OtherPTAN
FL390494600Medicaid