Healthcare Provider Details

I. General information

NPI: 1891888756
Provider Name (Legal Business Name): GLENN SYPERDA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7171 N DALE MABRY HWY
TAMPA FL
33614-2630
US

IV. Provider business mailing address

PO BOX 862810
ORLANDO FL
32886-2810
US

V. Phone/Fax

Practice location:
  • Phone: 352-867-8898
  • Fax: 352-732-6282
Mailing address:
  • Phone: 352-867-8898
  • Fax: 352-732-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberOS4956
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: