Healthcare Provider Details

I. General information

NPI: 1720113558
Provider Name (Legal Business Name): DOMINIQUE MESIDOR MD P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 CENTRAL AVE
ST PETERSBURG FL
33713-8900
US

IV. Provider business mailing address

PO BOX 16226
ST PETERSBURG FL
33733-6226
US

V. Phone/Fax

Practice location:
  • Phone: 727-896-1300
  • Fax: 727-896-1311
Mailing address:
  • Phone: 727-896-1300
  • Fax: 727-896-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME86398
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME86398
License Number StateFL

VIII. Authorized Official

Name: DOMINIQUE MESIDOR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 727-328-7400