Healthcare Provider Details

I. General information

NPI: 1902470826
Provider Name (Legal Business Name): DEIBIN LARROTA BARON SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2021
Last Update Date: 05/15/2021
Certification Date: 05/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6763 CAVACADE DR APT 51T
TAMPA FL
33614-4521
US

IV. Provider business mailing address

6763 CAVACADE DR APT 51T
TAMPA FL
33614-4521
US

V. Phone/Fax

Practice location:
  • Phone: 813-820-7470
  • Fax:
Mailing address:
  • Phone: 813-820-7470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number21-235
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: