Healthcare Provider Details

I. General information

NPI: 1336319045
Provider Name (Legal Business Name): MILOSLAVA MICIAN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3619 W WATERS AVE
TAMPA FL
33614-2783
US

IV. Provider business mailing address

3619 W WATERS AVE
TAMPA FL
33614-2783
US

V. Phone/Fax

Practice location:
  • Phone: 813-932-8866
  • Fax: 813-932-9668
Mailing address:
  • Phone: 813-932-8866
  • Fax: 813-932-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MILOSLAVA S MICIAN
Title or Position: PRESIDENT
Credential: MD
Phone: 813-932-8866