Basic Information
| Provider Information | |||||||||
| NPI: | 1598702276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TACSA-CARRASCO | ||||||||
| FirstName: | LEONCIO | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TACSA-CARRASCO | ||||||||
| OtherFirstName: | LEONCIO | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1111 7TH AVE N | ||||||||
| Address2: | STE 107 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278941661 | ||||||||
| FaxNumber: | 7278941430 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 7TH AVE N | ||||||||
| Address2: | STE 107 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278941661 | ||||||||
| FaxNumber: | 7278941430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 03/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME72300 | FL | Y | Other Service Providers | Specialist | 207R00000X | ME72300 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5533503 | 05 | NJ | MEDICAID |