Provider Demographics
NPI:1528041068
Name:RICHARD, DANA PHILLIP (DO)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:PHILLIP
Last Name:RICHARD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:309 E OCEAN AVE APT 103
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-3265
Mailing Address - Country:US
Mailing Address - Phone:561-434-5678
Mailing Address - Fax:786-221-4352
Practice Address - Street 1:2500 METROCENTRE BLVD
Practice Address - Street 2:SUITE 7
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3107
Practice Address - Country:US
Practice Address - Phone:561-434-5678
Practice Address - Fax:561-964-9829
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS5435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80230OtherBLUE CROSS BLUE SHIELD
FL80230ZMedicare ID - Type Unspecified
FL80230OtherBLUE CROSS BLUE SHIELD