Provider Demographics
NPI:1174966378
Name:PALSIS, JOHN ANDREW (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:PALSIS
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5550
Mailing Address - Fax:321-728-7553
Practice Address - Street 1:200 E HIBISCUS BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3156
Practice Address - Country:US
Practice Address - Phone:321-361-5550
Practice Address - Fax:321-728-7553
Is Sole Proprietor?:No
Enumeration Date:2013-04-08
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME140064207X00000X
LA309119207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104109100Medicaid
FLLM624OtherMEDICARE