Basic Information
| Provider Information | |||||||||
| NPI: | 1215330824 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GULF TO BAY INFECTIOUS DISEASE CONSULTANTS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4206 W BEACHWAY DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135411466 | ||||||||
| FaxNumber: | 8132818705 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 W SAINT ISABEL ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135411466 | ||||||||
| FaxNumber: | 8134140175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2014 | ||||||||
| LastUpdateDate: | 10/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | BUHARI | ||||||||
| AuthorizedOfficialFirstName: | MUDATHIRU | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8135411466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | ME 111588 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 505412 | 05 | FL | MEDICAID |