Healthcare Provider Details

I. General information

NPI: 1053611384
Provider Name (Legal Business Name): RAUL S BALAGTAS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10330 N DALE MABRY HWY STE 201
TAMPA FL
33618-4404
US

IV. Provider business mailing address

PO BOX 130009
TAMPA FL
33681-0009
US

V. Phone/Fax

Practice location:
  • Phone: 813-961-6633
  • Fax: 813-961-7733
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0059469
License Number StateFL

VIII. Authorized Official

Name: DR. RAUL S BALAGTAS
Title or Position: OWNER
Credential: MD
Phone: 813-964-3050