Basic Information
| Provider Information | |||||||||
| NPI: | 1790123271 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA ENDOCRINOLOGY & DIABETES CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2763 1ST AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276239913 | ||||||||
| FaxNumber: | 7278034852 | ||||||||
| Practice Location | |||||||||
| Address1: | 2763 1ST AVE N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337138723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276239913 | ||||||||
| FaxNumber: | 7278034852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2013 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | BUDHARAJU | ||||||||
| AuthorizedOfficialFirstName: | VENKATA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7276239913 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | ME108425 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 008900700 | 05 | FL | MEDICAID |