Provider Demographics
NPI:1386688257
Name:ROBERT C UDELL DO LLC
Entity Type:Organization
Organization Name:ROBERT C UDELL DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MSO CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-449-4168
Mailing Address - Street 1:150 N SYKES CREEK PKWY
Mailing Address - Street 2:# 300
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3488
Mailing Address - Country:US
Mailing Address - Phone:321-449-4168
Mailing Address - Fax:321-449-4164
Practice Address - Street 1:1980 N ATLANTIC AVE
Practice Address - Street 2:SUITE 1010
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5213
Practice Address - Country:US
Practice Address - Phone:321-868-0360
Practice Address - Fax:321-799-4968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF46064Medicare UPIN