Healthcare Provider Details

I. General information

NPI: 1518916972
Provider Name (Legal Business Name): SAMUEL GUBERNICK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13145 66TH ST N
LARGO FL
33773
US

IV. Provider business mailing address

13145 66TH ST N
LARGO FL
33773
US

V. Phone/Fax

Practice location:
  • Phone: 727-530-0700
  • Fax: 727-530-0777
Mailing address:
  • Phone: 727-530-0700
  • Fax: 727-530-0777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberOS5550
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberOS5550
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: