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Provider Information for 1821473299

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: 1821473299

Calendar   Last Updated:  2018-08-15
  Certification Date: 


Name Value
NPI 1821473299
Enumeration Date 2015-07-27
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: 727-266-4943
View Map External Link
Primary Practice Address 10330 N DALE MABRY HWY STE 190
TAMPA, FL 33618
United States

Phone: 813-969-4440 | Fax: 813-908-3290
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 022813000
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL OS14854
No 207Q00000X - Family Medicine FL UO4435