Healthcare Provider Details

I. General information

NPI: 1285059170
Provider Name (Legal Business Name): MINA GHOBRIAL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2014
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5398 PARK ST N
ST PETERSBURG FL
33709-1041
US

IV. Provider business mailing address

5398 PARK ST N
ST PETERSBURG FL
33709-1041
US

V. Phone/Fax

Practice location:
  • Phone: 727-544-1441
  • Fax: 727-545-8263
Mailing address:
  • Phone: 727-544-1441
  • Fax: 727-545-8263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number283883
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberOS18622
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: