Healthcare Provider Details

I. General information

NPI: 1578640181
Provider Name (Legal Business Name): MARIANO D CIBRAN, MD CORP DBA ST PETERSBURG PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 CENTRAL AVE
ST PETERSBURG FL
33713-8815
US

IV. Provider business mailing address

2115 CENTRAL AVE
ST PETERSBURG FL
33713-8815
US

V. Phone/Fax

Practice location:
  • Phone: 727-526-9135
  • Fax: 727-526-4346
Mailing address:
  • Phone: 727-526-9135
  • Fax: 727-526-4346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME27935
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARIANO D CIBRAN
Title or Position: PRESIDENT
Credential: MD
Phone: 727-526-9135