Provider Demographics
NPI:1164473096
Name:DEDO, DOUGLAS D (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:D
Last Name:DEDO
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 1:4060 PGA BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6574
Mailing Address - Country:US
Mailing Address - Phone:561-776-7112
Mailing Address - Fax:561-776-7113
Practice Address - Street 1:4060 PGA BLVD
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6574
Practice Address - Country:US
Practice Address - Phone:561-776-7112
Practice Address - Fax:561-776-7113
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30575174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55843Medicare UPIN
FL50803Medicare ID - Type Unspecified