Healthcare Provider Details

I. General information

NPI: 1336264035
Provider Name (Legal Business Name): UROLOGY PROFESSIONALS LLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 LITTLE RD
TRINITY FL
34655-4421
US

IV. Provider business mailing address

2075 LITTLE RD
TRINITY FL
34655-4421
US

V. Phone/Fax

Practice location:
  • Phone: 727-375-5520
  • Fax: 727-375-1463
Mailing address:
  • Phone: 727-375-5520
  • Fax: 727-375-1463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN OTHEGUY
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 727-375-5520