Skip Navigation

Provider Information for 1740254184

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: 1740254184

Calendar   Last Updated:  2021-05-27
  Certification Date:  2021-05-27


Name Value
NPI 1740254184
Enumeration Date 2006-02-14
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address PO BOX 47535
TAMPA, FL 33646-0113
United States

Phone: 813-755-0006 | Fax: 813-986-2731
View Map External Link
Primary Practice Address 5331 PRIMROSE LAKE CIR STE 112
TAMPA, FL 33647-3764
United States

Phone: 813-651-1085 | Fax:
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 024433500
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL ME68789