Provider Demographics
NPI:1801970538
Name:DEBALLI, PETER III (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:DEBALLI
Suffix:III
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 1:1600 S CARPENTER RD
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3619
Mailing Address - Country:US
Mailing Address - Phone:321-289-6914
Mailing Address - Fax:
Practice Address - Street 1:1600 S CARPENTER RD
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3619
Practice Address - Country:US
Practice Address - Phone:321-289-6914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89272207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37539ZMedicare ID - Type Unspecified