Healthcare Provider Details

I. General information

NPI: 1558394114
Provider Name (Legal Business Name): SERGIO J JACINTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 09/04/2020
Certification Date: 09/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4507 N ARMENIA AVE
TAMPA FL
33603-4742
US

IV. Provider business mailing address

4507 N ARMENIA AVE
TAMPA FL
33603-7770
US

V. Phone/Fax

Practice location:
  • Phone: 813-876-4100
  • Fax: 813-876-4153
Mailing address:
  • Phone: 813-876-4100
  • Fax: 813-876-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME66271
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberME66271
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: