Provider Demographics
NPI:1083724207
Name:PHILLIPS, JOEL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:WAYNE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 DRUID RD E
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3914
Mailing Address - Country:US
Mailing Address - Phone:727-446-1097
Mailing Address - Fax:727-441-2195
Practice Address - Street 1:708 DRUID RD E
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3914
Practice Address - Country:US
Practice Address - Phone:727-446-1097
Practice Address - Fax:727-441-2195
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0025848174400000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL038210800Medicaid
FL78457Medicare ID - Type Unspecified
FL038210800Medicaid