Basic Information
| Provider Information | |||||||||
| NPI: | 1659570851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CODOLOSA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | NICOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5398 PARK ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337091041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275441441 | ||||||||
| FaxNumber: | 7575458263 | ||||||||
| Practice Location | |||||||||
| Address1: | 5398 PARK ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337091041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275441441 | ||||||||
| FaxNumber: | 7575458263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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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 | 207RC0000X | ME121995 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 014728800 | 05 | FL | MEDICAID |