Provider Demographics
NPI:1104067032
Name:ARTHUR J DEBAISE MD PA
Entity type:Organization
Organization Name:ARTHUR J DEBAISE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEBAISE
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:407-539-3455
Mailing Address - Street 1:320 EDINBURGH DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792
Mailing Address - Country:US
Mailing Address - Phone:407-539-3455
Mailing Address - Fax:407-539-3481
Practice Address - Street 1:320 EDINBURGH DR
Practice Address - Street 2:SUITE A
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4157
Practice Address - Country:US
Practice Address - Phone:407-539-3455
Practice Address - Fax:407-539-3481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0057231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379448200Medicaid
G17641Medicare UPIN
FL26561Medicare PIN