Healthcare Provider Details

I. General information

NPI: 1316180300
Provider Name (Legal Business Name): CAROLYN D. PASS, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 07/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 1ST ST N
WINTER HAVEN FL
33881-4113
US

IV. Provider business mailing address

1255 STATE ROAD 60 E SUITE 100
LAKE WALES FL
33853-4310
US

V. Phone/Fax

Practice location:
  • Phone: 863-294-5505
  • Fax: 863-299-5660
Mailing address:
  • Phone: 863-676-8237
  • Fax: 863-676-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME73921
License Number StateFL

VIII. Authorized Official

Name: MRS. LINDA P WEAVER
Title or Position: CREDENTIALING/CONTRACTING
Credential:
Phone: 863-294-5505