Healthcare Provider Details

I. General information

NPI: 1780039636
Provider Name (Legal Business Name): TARIK KSAIBATI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8451 TEMPLE TERRACE HWY
TEMPLE TERRACE FL
33637-5853
US

IV. Provider business mailing address

8451 TEMPLE TERRACE HWY
TAMPA FL
33637-5853
US

V. Phone/Fax

Practice location:
  • Phone: 813-631-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberH0089254
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS15152
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: