Basic Information
| Provider Information | |||||||||
| NPI: | 1316068901 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOSEN | ||||||||
| FirstName: | KATINA | ||||||||
| MiddleName: | MELANIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6919 N DALE MABRY HWY STE 250 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336143860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139354210 | ||||||||
| FaxNumber: | 8139327940 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 S PINELLAS AVE STE J | ||||||||
| Address2: | |||||||||
| City: | TARPON SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346891951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7279433640 | ||||||||
| FaxNumber: | 7279429745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0011X | ME119622 | FL | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | 207P00000X | ME119622 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 014189400 | 05 | FL | MEDICAID | P01524561 | 01 | FL | RR MEDICARE | OTHER |