Provider Demographics
NPI:1699936492
Name:DR. ANTHONY L. CAPASSO M. D.
Entity type:Organization
Organization Name:DR. ANTHONY L. CAPASSO M. D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CAPASSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-249-9995
Mailing Address - Street 1:1351 13TH AVE S
Mailing Address - Street 2:STE # 110
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3234
Mailing Address - Country:US
Mailing Address - Phone:904-249-9995
Mailing Address - Fax:904-249-9449
Practice Address - Street 1:1351 13TH AVE S
Practice Address - Street 2:STE # 110
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3234
Practice Address - Country:US
Practice Address - Phone:904-249-9995
Practice Address - Fax:904-249-9449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 69518174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28510AOtherMEDICARE PTAN
FL=========OtherTAX IDENTIFICATION NUMBER
FLG63186Medicare UPIN