Healthcare Provider Details

I. General information

NPI: 1811182199
Provider Name (Legal Business Name): MICHAEL BRADLEY SMALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 VAN DYKE RD #200
LUTZ FL
33558-8005
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 813-264-6490
  • Fax: 813-443-8143
Mailing address:
  • Phone: 727-532-1355
  • Fax: 813-635-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME104627
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: