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Provider Information for 1821384280

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: 1821384280

Calendar   Last Updated:  2014-09-03
  Certification Date: 


Name Value
NPI 1821384280
Enumeration Date 2011-06-23
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address PO BOX 10744
CLEARWATER, FL 33757-8744
United States

Phone: 727-532-0002 | Fax: 727-266-4928
View Map External Link
Primary Practice Address 3231 MCMULLEN BOOTH RD
SAFETY HARBOR, FL 34695-6607
United States

Phone: 727-725-6526 | Fax: 727-266-4931
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 012730000
Primary Taxonomy Selected Taxonomy State License Number
Yes 208M00000X - Hospitalist FL ME114241
No 207Q00000X - Family Medicine FL ME114241