Provider Demographics
NPI:1134135007
Name:PHILLIPS, PAUL BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:BRUCE
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 1:4237 S PIPKIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33811-1442
Mailing Address - Country:US
Mailing Address - Phone:863-701-2470
Mailing Address - Fax:863-701-2474
Practice Address - Street 1:4237 S PIPKIN RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-1442
Practice Address - Country:US
Practice Address - Phone:863-701-2470
Practice Address - Fax:863-701-2474
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL71554207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG75478Medicare UPIN
FL43394XMedicare ID - Type Unspecified