Healthcare Provider Details

I. General information

NPI: 1558433359
Provider Name (Legal Business Name): YANINA J FIALLOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17541 N DALE MABRY HWY
LUTZ FL
33548-4521
US

IV. Provider business mailing address

17541 N DALE MABRY HWY
LUTZ FL
33548-4521
US

V. Phone/Fax

Practice location:
  • Phone: 813-964-1800
  • Fax: 813-964-1880
Mailing address:
  • Phone: 813-964-1800
  • Fax: 813-964-1880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME69011
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: