Provider Demographics
NPI:1396836706
Name:VULTAGGIO, BIAGIO V (MD)
Entity Type:Individual
Prefix:
First Name:BIAGIO
Middle Name:V
Last Name:VULTAGGIO
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 1:10010 BELLE RIVE BLVD
Mailing Address - Street 2:#1211
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-9056
Mailing Address - Country:US
Mailing Address - Phone:904-254-2459
Mailing Address - Fax:
Practice Address - Street 1:10010 BELLE RIVE BLVD
Practice Address - Street 2:#1211
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9056
Practice Address - Country:US
Practice Address - Phone:904-254-2459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP706207R00000X
FLME96271207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56679OtherBLUE CROSS BLUE SHIELD
FL276646900Medicaid
FL56679OtherBLUE CROSS BLUE SHIELD