Basic Information
| Provider Information | |||||||||
| NPI: | 1508228776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENGEL | ||||||||
| FirstName: | ELISSA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 DAVIS BLVD | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132502506 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17 DAVIS BLVD | ||||||||
| Address2: | SUITE 308 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132598725 | ||||||||
| FaxNumber: | 8132598792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2016 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | ME140182 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | LH984 | 01 | FL | MEDICARE | OTHER | 6WXGP | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 103295300 | 05 | FL | MEDICAID |