Healthcare Provider Details

I. General information

NPI: 1629133764
Provider Name (Legal Business Name): OLIVIA JOSEFINA SIFONTES ITDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 W DR MARTIN LUTHER KING JR BLVD
TAMPA FL
33614-7011
US

IV. Provider business mailing address

4001 W DR MARTIN LUTHER KING JR BLVD
TAMPA FL
33614-7011
US

V. Phone/Fax

Practice location:
  • Phone: 813-876-1605
  • Fax: 813-876-1620
Mailing address:
  • Phone: 813-876-1605
  • Fax: 813-876-1620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: