Healthcare Provider Details

I. General information

NPI: 1932107158
Provider Name (Legal Business Name): TAMARA THRELKELD PISTORIA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 06/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1033 N PARKWAY FRONTAGE RD
LAKELAND FL
33803-0401
US

IV. Provider business mailing address

PO BOX 95004
LAKELAND FL
33804-5004
US

V. Phone/Fax

Practice location:
  • Phone: 863-647-8011
  • Fax: 863-647-8029
Mailing address:
  • Phone: 863-680-7000
  • Fax: 863-680-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS0008614
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: