Provider Demographics
NPI:1922117845
Name:STAR SPORTS MEDICINE PA
Entity Type:Organization
Organization Name:STAR SPORTS MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIET
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DECAMPOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-479-3320
Mailing Address - Street 1:PO BOX 30010
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1010
Mailing Address - Country:US
Mailing Address - Phone:850-479-3320
Mailing Address - Fax:850-479-8789
Practice Address - Street 1:9400 UNIVERSITY PKWY
Practice Address - Street 2:SUITE 309
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5752
Practice Address - Country:US
Practice Address - Phone:850-479-3320
Practice Address - Fax:850-479-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253484300Medicaid
DG3210OtherMEDICARE RAILROAD
FL253484300Medicaid
FLK3488Medicare PIN