Healthcare Provider Details

I. General information

NPI: 1104337294
Provider Name (Legal Business Name): DESOTO LAKES EMERGENCY PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 SR 70 EAST
BRADENTON FL
34202
US

IV. Provider business mailing address

13737 NOEL RD
DALLAS TX
75240-1331
US

V. Phone/Fax

Practice location:
  • Phone: 469-401-2386
  • Fax:
Mailing address:
  • Phone: 954-838-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHY KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132