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Provider Information for 1417915190

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: 1417915190

Calendar   Last Updated:  2014-08-28
  Certification Date: 


Name Value
NPI 1417915190
Enumeration Date 2006-05-03
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 15320 AMBERLY DR SUITE B
TAMPA, FL 33647-1647
United States

Phone: 813-977-0733 | Fax: 813-971-2230
View Map External Link
Primary Practice Address 500 VONDERBURG DR SUITE 303-E
BRANDON, FL 33511-5964
United States

Phone: 813-681-5702 | Fax: 813-653-2376
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 207R00000X - Internal Medicine FL ME0030681