Provider Demographics
NPI:1457351983
Name:PHILLIPS, JESSE E (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:E
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 1:4632 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34981-5057
Mailing Address - Country:US
Mailing Address - Phone:772-464-9595
Mailing Address - Fax:772-460-2624
Practice Address - Street 1:4632 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34981-5057
Practice Address - Country:US
Practice Address - Phone:772-464-9595
Practice Address - Fax:772-460-2624
Is Sole Proprietor?:No
Enumeration Date:2005-07-27
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040385A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN00000209641OtherANTHEM BCBS
IN100462620AMedicaid
F35408Medicare UPIN
IN186050Medicare PIN