Healthcare Provider Details

I. General information

NPI: 1023784303
Provider Name (Legal Business Name): MICHAEL DESIMONE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35095 US HIGHWAY 19 N STE 101
PALM HARBOR FL
34684-1968
US

IV. Provider business mailing address

21756 STATE ROAD 54 STE 102
LUTZ FL
33549-2905
US

V. Phone/Fax

Practice location:
  • Phone: 727-475-5540
  • Fax:
Mailing address:
  • Phone: 727-475-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT37650
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: