Healthcare Provider Details

I. General information

NPI: 1659371441
Provider Name (Legal Business Name): MARGUERITE MARY KOHLHEPP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 VONDERBURG DR
BRANDON FL
33511-5982
US

IV. Provider business mailing address

403 VONDERBURG DR
BRANDON FL
33511-5982
US

V. Phone/Fax

Practice location:
  • Phone: 813-681-1122
  • Fax: 813-684-4924
Mailing address:
  • Phone: 813-681-1122
  • Fax: 813-684-4924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME0076125
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberME76125
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: