Provider Demographics
NPI:1861485518
Name:AMGOTT, THEODORE R (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:R
Last Name:AMGOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-725-4500
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1223 GATEWAY DR STE 2F
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4500
Practice Address - Fax:321-768-5082
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME44995207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040914600Medicaid
FL05519WOtherMEDICARE
FL05519OtherBCBS
FL05519OtherBCBS
FL110010966OtherRR MEDICARE