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Provider Information for 1558334789

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: 1558334789

Calendar   Last Updated:  2020-08-31
  Certification Date:  2020-08-31


Name Value
NPI 1558334789
Enumeration Date 2006-02-08
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 10051 5TH ST N STE 200
ST PETERSBURG, FL 33702-2211
United States

Phone: 727-824-0780 | Fax: 727-568-6011
View Map External Link
Primary Practice Address 2150 49TH ST N STE A
ST PETERSBURG, FL 33710-5237
United States

Phone: 727-828-1730 | Fax: 727-828-1731
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 265731700
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL OS8728