Healthcare Provider Details

I. General information

NPI: 1962463802
Provider Name (Legal Business Name): PEDRO A CARMONA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

951 N WASHINGTON AVE
TITUSVILLE FL
32796-2163
US

IV. Provider business mailing address

3450 BUSCHWOOD PARK DR SUITE 150
TAMPA FL
33618-4465
US

V. Phone/Fax

Practice location:
  • Phone: 321-268-6111
  • Fax: 321-268-6149
Mailing address:
  • Phone: 813-935-8501
  • Fax: 813-935-8541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberME42901
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: