Provider Demographics
NPI:1952375560
Name:UDELL, ROBERT C (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:UDELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 741268
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1268
Mailing Address - Country:US
Mailing Address - Phone:321-452-3811
Mailing Address - Fax:321-454-4026
Practice Address - Street 1:1980 N ATLANTIC AVE
Practice Address - Street 2:SUITE 1010
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5213
Practice Address - Country:US
Practice Address - Phone:321-868-0902
Practice Address - Fax:321-799-4968
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS7144207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57379ZMedicare ID - Type UnspecifiedPROVIDER NUMBER
FLA15902Medicare UPIN