Healthcare Provider Details

I. General information

NPI: 1629061007
Provider Name (Legal Business Name): TAMPA BAY ORTHOPAEDIC DESIGNS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 10/29/2026
Certification Date: 10/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 S KINGS AVE
BRANDON FL
33511-6048
US

IV. Provider business mailing address

1463 OAKFIELD DR STE 134
BRANDON FL
33511-0801
US

V. Phone/Fax

Practice location:
  • Phone: 813-224-0525
  • Fax: 813-315-9062
Mailing address:
  • Phone: 813-224-0525
  • Fax: 813-315-9062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPOR124
License Number StateFL

VIII. Authorized Official

Name: MR. OLAF MICKLE HOLM SR.
Title or Position: OWNER/PRESIDENT
Credential: LPO, CO, BOCPO
Phone: 813-224-0525