Healthcare Provider Details

I. General information

NPI: 1932605573
Provider Name (Legal Business Name): MIRIAM TUDYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 TAMPA GENERAL CIR
TAMPA FL
33606-3571
US

IV. Provider business mailing address

501 6TH AVE S
ST PETERSBURG FL
33701-4634
US

V. Phone/Fax

Practice location:
  • Phone: 813-844-7551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number2021018658
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberME152084
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: