Provider Demographics
NPI:1760553630
Name:NEILY, JOHN GREGORY (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GREGORY
Last Name:NEILY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21550 ANGELA LN
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-2017
Mailing Address - Country:US
Mailing Address - Phone:941-493-7400
Mailing Address - Fax:941-493-1940
Practice Address - Street 1:21550 ANGELA LN
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-2017
Practice Address - Country:US
Practice Address - Phone:941-493-7400
Practice Address - Fax:941-493-1940
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80963OtherBLUE SHIELD ID NUMBER
FLE82043Medicare UPIN
K3656Medicare PIN