Provider Demographics
NPI:1891159745
Name:CAO, PHILLIPS
Entity Type:Individual
Prefix:
First Name:PHILLIPS
Middle Name:
Last Name:CAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4308
Mailing Address - Country:US
Mailing Address - Phone:315-801-1149
Mailing Address - Fax:315-801-3565
Practice Address - Street 1:450077 STATE ROAD 200 STE 12
Practice Address - Street 2:
Practice Address - City:CALLAHAN
Practice Address - State:FL
Practice Address - Zip Code:32011-3863
Practice Address - Country:US
Practice Address - Phone:904-633-0561
Practice Address - Fax:315-801-3565
Is Sole Proprietor?:No
Enumeration Date:2016-04-07
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140356207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine