Healthcare Provider Details

I. General information

NPI: 1891085189
Provider Name (Legal Business Name): MORIAM O AYO AMU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10141 BIG BEND RD. SUITE 101
RIVERVIEW FL
33578-7419
US

IV. Provider business mailing address

PO BOX 10744
CLEARWATER FL
33757-8744
US

V. Phone/Fax

Practice location:
  • Phone: 813-397-1270
  • Fax: 813-397-1271
Mailing address:
  • Phone: 727-532-0002
  • Fax: 727-266-4943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME114970
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: