Provider Demographics
NPI:1194728121
Name:BADOLATO, DAVID W (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:BADOLATO
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 1:6300 N. WICKHAM RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:321-433-1534
Mailing Address - Fax:
Practice Address - Street 1:6300 N WICKHAM RD
Practice Address - Street 2:STE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2028
Practice Address - Country:US
Practice Address - Phone:321-253-2169
Practice Address - Fax:321-253-1720
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76812207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
49716XMedicare PIN
FLH11062Medicare UPIN
FL49716ZMedicare PIN