Healthcare Provider Details

I. General information

NPI: 1649808569
Provider Name (Legal Business Name): JAMESON GRANT DARIA WIENER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13330 USF LAUREL DR FL 6
TAMPA FL
33612-6601
US

IV. Provider business mailing address

13330 USF LAUREL DR FL 6
TAMPA FL
33612-6601
US

V. Phone/Fax

Practice location:
  • Phone: 813-821-8034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME177574
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: