Healthcare Provider Details

I. General information

NPI: 1275876047
Provider Name (Legal Business Name): JOAO CLEBES DOS SANTOS FONTOURA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 S LAKEWOOD DR
BRANDON FL
33511-2815
US

IV. Provider business mailing address

313 S LAKEWOOD DR
BRANDON FL
33511-2815
US

V. Phone/Fax

Practice location:
  • Phone: 813-653-6100
  • Fax:
Mailing address:
  • Phone: 813-653-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME124990
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME124990
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: