Provider Demographics
NPI:1881930857
Name:ANTHONY DECOTIS, M.D.,P.A.
Entity type:Organization
Organization Name:ANTHONY DECOTIS, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DECOTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-243-8558
Mailing Address - Street 1:131 BEAL PKWY NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4358
Mailing Address - Country:US
Mailing Address - Phone:850-243-8558
Mailing Address - Fax:850-301-0147
Practice Address - Street 1:131 BEAL PKWY NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4358
Practice Address - Country:US
Practice Address - Phone:850-243-8558
Practice Address - Fax:850-301-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45093207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047222100Medicaid
FL17617OtherBLUE COSS BLUE SHIELD OF FLORIDA
FL17617OtherBLUE COSS BLUE SHIELD OF FLORIDA
FL047222100Medicaid