Provider Demographics
NPI:1821090838
Name:BRILL, JACQUELINE M (DPM)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:M
Last Name:BRILL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4302 ALTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2891
Mailing Address - Country:US
Mailing Address - Phone:305-893-9366
Mailing Address - Fax:305-893-4408
Practice Address - Street 1:4302 ALTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2891
Practice Address - Country:US
Practice Address - Phone:305-893-9366
Practice Address - Fax:305-893-4408
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2613213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390333800Medicaid
FL390333800Medicaid
FL65483ZMedicare ID - Type UnspecifiedMEDICARE