Provider Demographics
NPI:1366624827
Name:WIRT, PHILIP RICHARD III (DO)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:RICHARD
Last Name:WIRT
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9494 WATEROAK CT
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34453-1707
Mailing Address - Country:US
Mailing Address - Phone:352-860-2137
Mailing Address - Fax:352-860-2137
Practice Address - Street 1:9494 WATEROAK CT
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-1707
Practice Address - Country:US
Practice Address - Phone:352-860-2137
Practice Address - Fax:352-860-2137
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4043207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine