Healthcare Provider Details

I. General information

NPI: 1164766002
Provider Name (Legal Business Name): JOSE R. FORADADA, III, MD, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4710 N. HABANA AVE. SUITE 307
TAMPA FL
33614-7151
US

IV. Provider business mailing address

4710 N. HABANA AVE. SUITE 307
TAMPA FL
33614-7151
US

V. Phone/Fax

Practice location:
  • Phone: 813-874-2000
  • Fax:
Mailing address:
  • Phone: 813-874-2000
  • Fax: 813-874-9303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP3390982
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP9263175
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberME0056885
License Number StateFL

VIII. Authorized Official

Name: DR. JOSE RAMON FORADADA III
Title or Position: PRESIDENT
Credential: M.D.
Phone: 813-874-2000