MEDICARE: DIS OF TAMPA BAY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1609422146
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIS OF TAMPA BAY INC

Provider Business Mailing Address
First Line	:	3635 W WATERS AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-2783
Country	:	US
Telephone Number	:	813-724-3310
Fax Number	:	813-280-4923

Provider Business Practice Location Address
First Line	:	3635 W WATERS AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-2783
Country	:	US
Telephone Number	:	813-408-9161
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. LESSY RODRIGUEZ
Credential	:
Telephone Number	:	813-724-3310

Provider Enumeration Date	:	08/12/2019
Last Update Date	:	01/30/2020

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