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Provider Information for 1871738948

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: 1871738948

Calendar   Last Updated:  2014-10-09
  Certification Date: 


Name Value
NPI 1871738948
Enumeration Date 2008-12-03
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address PO BOX 1829
CLEARWATER, FL 33757-1829
United States

Phone: 727-532-0002 | Fax: 727-266-4928
View Map External Link
Primary Practice Address 1201 5TH AVE N SUITE 202
ST PETERSBURG, FL 33705-1410
United States

Phone: 727-820-7701 | Fax: 727-820-7700
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 012991700
Primary Taxonomy Selected Taxonomy State License Number
Yes 2084N0008X - Psychiatry & Neurology Neuromuscular Medicine FL ME120668