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General NPI Number Information
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NPI Number | 1285024380
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Entity Type | Organization
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Legal Business Name | NORTHDALE FAMILY DR
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Dates
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Enumeration Date | 01/27/2015
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Last Update Date | 01/27/2015
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Provider Practice Location Address
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Address Line | 3865 NORTHDALE BLVD
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City | TAMPA
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State | FL
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Zip | 33624-1861
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Country | US
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Telephone | 813-960-4401
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Fax |
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Provider Business Mailing Address
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Address Line | 3865 NORTHDALE BLVD
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City | TAMPA
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State | FL
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Zip | 33624-1861
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Country | US
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Telephone | 813-960-4401
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Fax |
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | DR. YAKUB AHMED POTHIAWALA
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Credential | MD
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Telephone | 813-960-4401
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME0070225
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License Number State | FL
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