Healthcare Provider Details

I. General information

NPI: 1437184090
Provider Name (Legal Business Name): SUNSHINE STATE SURGICAL SPECIALISTS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1879 NIGHTINGALE LANE SUITE B3
TAVARES FL
32778
US

IV. Provider business mailing address

PO BOX 547
TAVARES FL
32778
US

V. Phone/Fax

Practice location:
  • Phone: 352-742-1300
  • Fax: 352-742-1305
Mailing address:
  • Phone: 352-742-1300
  • Fax: 352-742-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME88645
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME88645
License Number StateFL

VIII. Authorized Official

Name: DAVID S BJERKEN
Title or Position: OWNER
Credential: MD
Phone: 352-742-1300