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General NPI Number Information
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NPI Number | 1669745162
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Entity Type | Organization
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Legal Business Name | BONITA J DRAKE M.D, P.A
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Dates
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Enumeration Date | 02/14/2012
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Last Update Date | 02/14/2012
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Provider Practice Location Address
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Address Line | 3950 3RD ST N
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City | SAINT PETERSBURG
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State | FL
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Zip | 33703-6123
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Country | US
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Telephone | 727-821-0612
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Fax | 727-822-5507
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Provider Business Mailing Address
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Address Line | 3950 3RD ST N
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City | SAINT PETERSBURG
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State | FL
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Zip | 33703-6123
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Country | US
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Telephone | 727-821-0612
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Fax | 727-822-5507
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Authorized Official
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Title or Position | OWNER
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Name | DR. BONITA J DRAKE
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Credential | M.D.
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Telephone | 727-821-0612
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | ME15815
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License Number State | FL
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