Healthcare Provider Details

I. General information

NPI: 1629070974
Provider Name (Legal Business Name): BRENT D MOOK SANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 BLOOMINGDALE AVE STE 223
VALRICO FL
33596-6403
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 813-689-7139
  • Fax: 813-443-8157
Mailing address:
  • Phone: 727-532-1355
  • Fax: 813-635-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME44540
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: