Healthcare Provider Details

I. General information

NPI: 1740603547
Provider Name (Legal Business Name): GAELLE LAURORE-FRAY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 N 22ND ST
TAMPA FL
33610-6205
US

IV. Provider business mailing address

PO BOX 82969
TAMPA FL
33682-2969
US

V. Phone/Fax

Practice location:
  • Phone: 813-272-6240
  • Fax: 813-247-5591
Mailing address:
  • Phone: 813-866-0930
  • Fax: 813-405-3924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS 12507
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: