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Provider Information for 1255726683

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: 1255726683

Calendar   Last Updated:  2019-12-24
  Certification Date:  2019-12-24


Name Value
NPI 1255726683
Enumeration Date 2015-04-02
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 14690 SPRING HILL DR STE 305
SPRING HILL, FL 34609-8102
United States

Phone: 352-277-5348 | Fax: 352-606-2857
View Map External Link
Primary Practice Address 13235 STATE ROAD 52 STE 102
HUDSON, FL 34669
United States

Phone: 727-378-8503 | Fax: 727-378-5806
View Map External Link
Secondary Practice Address 8365 S SUNCOAST BLVD
HOMOSASSA, FL 34446-5028
United States

Phone: 352-382-0258 | Fax: 352-382-0416
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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 OS14546