Healthcare Provider Details

I. General information

NPI: 1972704070
Provider Name (Legal Business Name): GARY JO LIENHART DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11231 LAKE LANIER DR
RIVERVIEW FL
33569-2935
US

IV. Provider business mailing address

11231 LAKE LANIER DR
RIVERVIEW FL
33569-2935
US

V. Phone/Fax

Practice location:
  • Phone: 727-230-1576
  • Fax: 727-230-1604
Mailing address:
  • Phone: 727-230-1576
  • Fax: 727-230-1604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number5101015979
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS10592
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: