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Provider Information for 1093972143

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1093972143

Calendar   Last Updated:  2021-05-27
  Certification Date:  2021-05-27


Name Value
NPI 1093972143
Enumeration Date 2008-05-16
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 10015 SPANISH CHERRY CT
TAMPA, FL 33647-3715
United States

Phone: 941-545-2895 | Fax: 813-289-6592
View Map External Link
Primary Practice Address 5331 PRIMROSE LAKE CIR STE 112
TAMPA, FL 33647-3764
United States

Phone: 813-651-1085 | Fax: 813-932-0266
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL ME102401