Healthcare Provider Details

I. General information

NPI: 1407891302
Provider Name (Legal Business Name): OKUN AND MADDALON M.D. PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 W ROBERTSON ST STE 102
BRANDON FL
33511-4934
US

IV. Provider business mailing address

721 W ROBERTSON ST STE 102
BRANDON FL
33511-4934
US

V. Phone/Fax

Practice location:
  • Phone: 813-684-3707
  • Fax: 813-654-3671
Mailing address:
  • Phone: 813-684-3707
  • Fax: 813-643-2457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0044550
License Number StateFL

VIII. Authorized Official

Name: MRS. JOHN DAVID OKUN
Title or Position: PRESIDENT
Credential: MD
Phone: 813-684-3707