Provider Demographics
NPI:1073735833
Name:FAMILY CARE OF LAND O LAKES PA
Entity Type:Organization
Organization Name:FAMILY CARE OF LAND O LAKES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:ROSEQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-948-3838
Mailing Address - Street 1:1942 HIGHLAND OAKS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7410
Mailing Address - Country:US
Mailing Address - Phone:813-948-3838
Mailing Address - Fax:813-949-0629
Practice Address - Street 1:1942 HIGHLAND OAKS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33559-7410
Practice Address - Country:US
Practice Address - Phone:813-948-3838
Practice Address - Fax:813-949-0629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0048283207Q00000X
FL0040424207Q00000X
FLME20601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD50540Medicare UPIN
FLD09214Medicare UPIN
FLD65093Medicare UPIN
53682YMedicare PIN
FLAN400ZMedicare PIN
FL53682Medicare ID - Type UnspecifiedDR. STANLEY E. WATKINS
FL02510Medicare ID - Type UnspecifiedDR. ROBERT B. ROSEQUIST
FLE6042UMedicare PIN
FL02510YMedicare PIN