Healthcare Provider Details

I. General information

NPI: 1053338954
Provider Name (Legal Business Name): BRANDON CARDIOLOGY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 OAKFIELD DR
BRANDON FL
33511-5723
US

IV. Provider business mailing address

321 E ROBERTSON ST
BRANDON FL
33511-5253
US

V. Phone/Fax

Practice location:
  • Phone: 813-689-1912
  • Fax: 813-684-3335
Mailing address:
  • Phone: 813-685-2191
  • Fax: 813-689-8755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: DALLAS DUNNE
Title or Position: BILLING REP
Credential:
Phone: 813-685-2191