Provider Demographics
NPI:1679567697
Name:COMITALO, JEFFREY BRIAN (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:BRIAN
Last Name:COMITALO
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 1:8333 N DAVIS HWY
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6050
Mailing Address - Country:US
Mailing Address - Phone:850-474-8342
Mailing Address - Fax:850-969-2886
Practice Address - Street 1:8333 N DAVIS HWY
Practice Address - Street 2:5TH FLOOR
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6050
Practice Address - Country:US
Practice Address - Phone:850-474-8342
Practice Address - Fax:850-969-2886
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74536208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25329900Medicaid
FL006517900Medicaid
AL529909680Medicaid
FL42469AMedicare ID - Type Unspecified
AL529909680Medicaid
FL006517900Medicaid