Provider Demographics
NPI:1841470952
Name:GABRIEL A DECANDIDO PA
Entity type:Organization
Organization Name:GABRIEL A DECANDIDO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-536-0441
Mailing Address - Street 1:PO BOX 2056
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33779-2056
Mailing Address - Country:US
Mailing Address - Phone:727-536-0441
Mailing Address - Fax:727-535-1985
Practice Address - Street 1:8005 ULMERTON RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-3971
Practice Address - Country:US
Practice Address - Phone:727-536-0441
Practice Address - Fax:727-535-1985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL068744800Medicaid
FL21140Medicare PIN