Healthcare Provider Details

I. General information

NPI: 1679951347
Provider Name (Legal Business Name): BILL FOO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10729 QUEENS TOWN DR
RIVERVIEW FL
33579-7186
US

IV. Provider business mailing address

720 BROOKER CREEK BLVD STE 215
OLDSMAR FL
34677-2937
US

V. Phone/Fax

Practice location:
  • Phone: 813-672-3497
  • Fax: 813-741-2418
Mailing address:
  • Phone: 813-854-2003
  • Fax: 813-436-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA155650
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME157305
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME157305
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: