Provider Demographics
NPI:1629020631
Name:DUCILLE, DONNA L (DO)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:DUCILLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:142
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5742
Mailing Address - Country:US
Mailing Address - Phone:954-472-2999
Mailing Address - Fax:954-473-8171
Practice Address - Street 1:6037 KIMBERLY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-2811
Practice Address - Country:US
Practice Address - Phone:954-379-8994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8172207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260352700Medicaid
FLE5552Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID
FL260352700Medicaid