=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548464480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY AREA OB GYN, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13801 BRUCE B DOWNS BLVD 201
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33613-3946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-975-9788
-----------------------------------------------------
Fax | 813-971-9716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13801 BRUCE B DOWNS BLVD 201
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33613-3946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-975-9788
-----------------------------------------------------
Fax | 813-971-9716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HOWARD ULYSESS JOHNSON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 813-975-9788
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME49037
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------