Provider Demographics
NPI:1194716431
Name:PHILLIPS, PAUL LESLIE (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:LESLIE
Last Name:PHILLIPS
Suffix:
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 1:455 PINELLAS ST
Mailing Address - Street 2:STE 400
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3356
Mailing Address - Country:US
Mailing Address - Phone:727-445-1911
Mailing Address - Fax:727-445-1986
Practice Address - Street 1:455 PINELLAS ST
Practice Address - Street 2:STE 400
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3356
Practice Address - Country:US
Practice Address - Phone:727-445-1911
Practice Address - Fax:727-445-1986
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40180207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067126600Medicaid
FL067126600Medicaid
FL62356OtherBLUE CROSS BLUE SHIELD
FL067126600Medicaid