Provider Demographics
NPI:1346223658
Name:DEFILIPPO, ANTONIO FORTUNATO
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:FORTUNATO
Last Name:DEFILIPPO
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:ANTONIO
Other - Middle Name:
Other - Last Name:DEFILIPPO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2225 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3611
Mailing Address - Country:US
Mailing Address - Phone:954-962-6200
Mailing Address - Fax:954-962-5495
Practice Address - Street 1:2225 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3611
Practice Address - Country:US
Practice Address - Phone:954-962-6200
Practice Address - Fax:954-962-5495
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6507388012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377771500Medicaid
26810Medicare ID - Type Unspecified
FL377771500Medicaid