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Provider Information for 1992763650

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: 1992763650

Calendar   Last Updated:  2014-08-20
  Certification Date: 


Name Value
NPI 1992763650
Enumeration Date 2006-05-03
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 15320 AMBERLY DR SUITE B
TAMPA, FL 33647-1647
United States

Phone: 813-977-0733 | Fax: 813-971-2230
View Map External Link
Primary Practice Address 11924 SHELDON RD
TAMPA, FL 33626-3643
United States

Phone: 813-926-2177 | Fax: 813-926-7489
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL ME0050538