Healthcare Provider Details

I. General information

NPI: 1780010512
Provider Name (Legal Business Name): YANINA ABAUNZA-FIALLOS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17541 N. DALE MABRY HWY.
LUTZ FL
33548
US

IV. Provider business mailing address

17541 N. DALE MABRY HWY.
LUTZ FL
33548
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: GOWTHAM PANDIAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 813-964-1800