Provider Demographics
NPI:1801090246
Name:PITTS, BLAINE BRADLEY (MD)
Entity type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:BRADLEY
Last Name:PITTS
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 1:92 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:321-841-2245
Mailing Address - Fax:321-843-6624
Practice Address - Street 1:92 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:321-841-2245
Practice Address - Fax:321-843-6624
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH093600208000000X
MO2005018765208000000X
FLME1105442080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME110544OtherMEDICAL LICENSE
FL003827200Medicaid
FLFK680ZMedicare PIN