Provider Demographics
NPI:1215991690
Name:BELLAFIORE, JACK M (PA-C)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:BELLAFIORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 N OLIVE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-3520
Mailing Address - Country:US
Mailing Address - Phone:561-655-4450
Mailing Address - Fax:561-655-4469
Practice Address - Street 1:1117 N OLIVE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-3520
Practice Address - Country:US
Practice Address - Phone:561-655-4450
Practice Address - Fax:561-655-4469
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291679700Medicaid
FLU1681YMedicare ID - Type Unspecified
FLU1681ZMedicare ID - Type Unspecified
FL291679700Medicaid