Healthcare Provider Details

I. General information

NPI: 1740292804
Provider Name (Legal Business Name): JAMIE TODD CARACCIOLO MD, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12902 USF MAGNOLIA DR
TAMPA FL
33612-9416
US

IV. Provider business mailing address

PO BOX 198441 MBC-MMG
ATLANTA GA
30384-8441
US

V. Phone/Fax

Practice location:
  • Phone: 813-745-7365
  • Fax: 813-449-8618
Mailing address:
  • Phone: 813-745-7365
  • Fax: 813-449-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number227292
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME98138
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: