Provider Demographics
NPI:1043280142
Name:LETSON, GEORGE DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:DOUGLAS
Last Name:LETSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 N DUNDEE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6406
Mailing Address - Country:US
Mailing Address - Phone:813-745-3976
Mailing Address - Fax:813-745-8337
Practice Address - Street 1:12902 MAGNOLIA DR
Practice Address - Street 2:SUITE 5036
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-3976
Practice Address - Fax:813-745-8337
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0064409174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373191000Medicaid
FL12167OtherBLUE CROSS BLUE SHIELD
FL373191000Medicaid
FL12167OtherBLUE CROSS BLUE SHIELD