Basic Information
Provider Information | |||||||||
NPI: | 1962669986 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TAMPA OBSTETRICS, P.A. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 505 OAKFIELD DR | ||||||||
Address2: |   | ||||||||
City: | BRANDON | ||||||||
State: | FL | ||||||||
PostalCode: | 335115700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136542273 | ||||||||
FaxNumber: | 8136541384 | ||||||||
Practice Location | |||||||||
Address1: | 215 IMPERIAL BLVD | ||||||||
Address2: | SUITE B2 | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338034689 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136542273 | ||||||||
FaxNumber: | 8136541384 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2008 | ||||||||
LastUpdateDate: | 09/25/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MAYO | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 8136542273 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 051857300 | 05 | FL |   | MEDICAID |