Provider Demographics
NPI:1831474303
Name:JOHN B. DECOSMO,III, D.O., P.A.
Entity Type:Organization
Organization Name:JOHN B. DECOSMO,III, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:DECOSMO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-498-6488
Mailing Address - Street 1:4800 4TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-3817
Mailing Address - Country:US
Mailing Address - Phone:727-498-6488
Mailing Address - Fax:727-362-6772
Practice Address - Street 1:4800 4TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-3817
Practice Address - Country:US
Practice Address - Phone:727-498-6488
Practice Address - Fax:727-362-6772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2015-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5534261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE31898Medicare UPIN