Basic Information
| Provider Information | |||||||||
| NPI: | 1396845400 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIAGNOSTIC PATHOLOGY OF FLORIDA SUNCOAST, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5901 SW 74TH ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331435165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056654614 | ||||||||
| FaxNumber: | 3056670239 | ||||||||
| Practice Location | |||||||||
| Address1: | 10461 QUALITY DR | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346099634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056654614 | ||||||||
| FaxNumber: | 3056670239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | COLINA | ||||||||
| AuthorizedOfficialFirstName: | LEDWINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 3526888200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 379639600 | 05 | FL | MEDICAID |