Healthcare Provider Details

I. General information

NPI: 1790101608
Provider Name (Legal Business Name): JONATHAN ROSS DATTILO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2014
Last Update Date: 03/28/2026
Certification Date: 03/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12416 66TH ST STE A
LARGO FL
33773-3430
US

IV. Provider business mailing address

12416 66TH ST STE A
LARGO FL
33773-3430
US

V. Phone/Fax

Practice location:
  • Phone: 727-547-4700
  • Fax: 727-394-8661
Mailing address:
  • Phone: 727-547-4700
  • Fax: 727-394-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberME144420
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: