Healthcare Provider Details

I. General information

NPI: 1609280403
Provider Name (Legal Business Name): 13701 BRUCE B DOWNS BOULEVARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13701 BRUCE B DOWNS BLVD SUITE 101
TAMPA FL
33613-4647
US

IV. Provider business mailing address

13701 BRUCE B DOWNS BLVD SUITE 101
TAMPA FL
33613-4647
US

V. Phone/Fax

Practice location:
  • Phone: 813-979-9580
  • Fax: 813-979-1574
Mailing address:
  • Phone: 813-979-9580
  • Fax: 813-979-1574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS MARISOL RODRIGUEZ
Title or Position: BILLING MANAGER
Credential:
Phone: 813-979-9580