Provider Demographics
NPI:1093820417
Name:ADILI, TAGRID (MD PA)
Entity Type:Individual
Prefix:
First Name:TAGRID
Middle Name:
Last Name:ADILI
Suffix:
Gender:F
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 NW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983
Mailing Address - Country:US
Mailing Address - Phone:772-807-7166
Mailing Address - Fax:772-807-7169
Practice Address - Street 1:463 NW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983
Practice Address - Country:US
Practice Address - Phone:772-335-1882
Practice Address - Fax:772-807-7169
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME672742084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
26511Medicare PIN
FLG22352Medicare UPIN