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Provider Information for 1356654198

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: 1356654198

Calendar   Last Updated:  2015-05-22
  Certification Date: 


Name Value
NPI 1356654198
Enumeration Date 2010-07-21
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 500 VONDERBURG DR SUITE 311 W
BRANDON, FL 33511-5964
United States

Phone: 813-654-2445 | Fax: 813-654-9885
View Map External Link
Primary Practice Address 282 APOLLO BEACH BLVD
APOLLO BEACH, FL 33572-2261
United States

Phone: 813-645-4068 | Fax: 813-654-0312
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 OS11557