Healthcare Provider Details

I. General information

NPI: 1497844120
Provider Name (Legal Business Name): TARIQ KUTOB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 66TH ST N STE 101
PINELLAS PARK FL
33781-2101
US

IV. Provider business mailing address

7800 66TH ST N STE 101
PINELLAS PARK FL
33781-2101
US

V. Phone/Fax

Practice location:
  • Phone: 727-546-5702
  • Fax: 727-546-5700
Mailing address:
  • Phone: 727-546-5702
  • Fax: 727-546-5700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301060391
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME156735
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: