Provider Demographics
NPI:1598887275
Name:BOCCARDO, JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BOCCARDO
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 1:2401 FRIST BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4800
Mailing Address - Country:US
Mailing Address - Phone:772-595-5302
Mailing Address - Fax:772-595-5304
Practice Address - Street 1:2401 FRIST BLVD STE 4
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4800
Practice Address - Country:US
Practice Address - Phone:772-595-5302
Practice Address - Fax:772-595-5304
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4323162086S0129X
FLME1258762086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102479013 0001Medicaid
PA102479013 0001Medicaid