Provider Demographics
NPI:1568451813
Name:DECUBELLIS, PHILLIP D (DPM)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:D
Last Name:DECUBELLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2828 E COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4206
Mailing Address - Country:US
Mailing Address - Phone:954-776-5700
Mailing Address - Fax:
Practice Address - Street 1:2828 E COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4206
Practice Address - Country:US
Practice Address - Phone:954-776-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1934213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052057800Medicaid
FL4291020001Medicare NSC
FL65056DMedicare ID - Type Unspecified
FLT77545Medicare UPIN