Healthcare Provider Details

I. General information

NPI: 1174571277
Provider Name (Legal Business Name): IRA FIALKO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6171 W GULF TO LAKE HWY
CRYSTAL RIVER FL
34429-2679
US

IV. Provider business mailing address

6171 W GULF TO LAKE HWY
CRYSTAL RIVER FL
34429-2679
US

V. Phone/Fax

Practice location:
  • Phone: 352-563-0220
  • Fax: 352-563-0706
Mailing address:
  • Phone: 352-563-0220
  • Fax: 352-563-0706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS4404
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: