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Provider Information for 1366862237

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: 1366862237

Calendar   Last Updated:  2019-10-09
  Certification Date: 


Name Value
NPI 1366862237
Enumeration Date 2014-04-18
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 2995 DREW ST FL 2
CLEARWATER, FL 33759-3012
United States

Phone: 727-532-1355 | Fax: 813-635-2613
View Map External Link
Primary Practice Address 2102 TRINITY OAKS BLVD STE 216
TRINITY, FL 34655-4409
United States

Phone: 727-372-2501 | Fax: 813-635-2698
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
MEDICAID FL 021767800
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL ME125718
No 390200000X - Student in an Organized Health Care Education/Training Program