Basic Information
| Provider Information | |||||||||
| NPI: | 1639288137 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUDINO | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1967 SHORE ACRES BLVD NE | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275226687 | ||||||||
| FaxNumber: | 7275269280 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 W BEARSS AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195312127 | ||||||||
| FaxNumber: | 4195312664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | ME68779 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 250011108 | 01 | FL | RR MEDICARE | OTHER | 27430 | 01 | FL | BLUE SHIELD | OTHER | 250010137 | 01 | FL | RR MEDICARE | OTHER | 253156900 | 05 | FL | MEDICAID | 250010136 | 01 | FL | RR MEDICARE | OTHER |