Healthcare Provider Details

I. General information

NPI: 1205518040
Provider Name (Legal Business Name): LOMBA MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 N SUNCOAST BLVD
CRYSTAL RIVER FL
34428-6712
US

IV. Provider business mailing address

PO BOX 742291
ATLANTA GA
30374-2291
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-8338
  • Fax:
Mailing address:
  • Phone: 941-766-4267
  • Fax: 941-766-4123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: FERNANDO LUIS LOMBA
Title or Position: PRESIDENT
Credential: MD
Phone: 941-766-4120