Provider Demographics
NPI:1457351983
Name:PHILLIPS, JESSE E (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:E
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 SE HILLMOOR DR
Mailing Address - Street 2:SUITE B105
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7545
Mailing Address - Country:US
Mailing Address - Phone:772-398-9911
Mailing Address - Fax:772-398-4374
Practice Address - Street 1:1801 SE HILLMOOR DR
Practice Address - Street 2:SUITE B105
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7553
Practice Address - Country:US
Practice Address - Phone:772-398-9911
Practice Address - Fax:772-398-4374
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040385A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000209641OtherANTHEM BCBS
IN100462620AMedicaid
F35408Medicare UPIN
IN186050Medicare PIN