Basic Information
| Provider Information | |||||||||
| NPI: | 1316310501 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IAN K MUSGRAVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 320341 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336792341 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 119 OAKFIELD DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554212733 | ||||||||
| FaxNumber: | 3212802479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2015 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | MUSGRAVE | ||||||||
| AuthorizedOfficialFirstName: | IAN | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2023091520 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.