Healthcare Provider Details

I. General information

NPI: 1619187473
Provider Name (Legal Business Name): TAMARA PISTORIA D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVENUE K SE STE 5
WINTER HAVEN FL
33880-4146
US

IV. Provider business mailing address

400 AVENUE K SE STE 5
WINTER HAVEN FL
33880-4146
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-3909
  • Fax:
Mailing address:
  • Phone: 863-293-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOF0008614
License Number StateFL

VIII. Authorized Official

Name: TAMARA PISTORIA
Title or Position: OWNER
Credential: D.O.
Phone: 863-293-3909