Provider Demographics
NPI:1790753853
Name:FOX, AMY MELINA DOSORETZ (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MELINA DOSORETZ
Last Name:FOX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MELINA
Other - Last Name:DOSORETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3080 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6720
Mailing Address - Country:US
Mailing Address - Phone:941-883-2199
Mailing Address - Fax:941-979-5041
Practice Address - Street 1:3080 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952
Practice Address - Country:US
Practice Address - Phone:941-883-2199
Practice Address - Fax:941-979-5041
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1056362085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL146MGOtherBCBS FL
FL001487200Medicaid
FL001487200Medicaid
FLP00762061OtherRR MEDICARE
FLSG102266OtherVISTA HEALTH PLAN
FL332989OtherAVMED THRU LEE PHO
FL1018337OtherWELLCARE (STAYWELL-MEDICAID AND WELLCARE-MEDICARE)
FL146MGOtherBCBS FL
FLCH897ZMedicare PIN