Provider Demographics
NPI:1124038989
Name:CORNERSTONE MEDICAL CARE OF BRANDON LLC
Entity Type:Organization
Organization Name:CORNERSTONE MEDICAL CARE OF BRANDON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:ENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-681-5658
Mailing Address - Street 1:500 VONDERBURG DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5968
Mailing Address - Country:US
Mailing Address - Phone:813-681-5658
Mailing Address - Fax:813-681-5250
Practice Address - Street 1:500 VONDERBURG DR
Practice Address - Street 2:E TOWER STE 102
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5964
Practice Address - Country:US
Practice Address - Phone:813-681-5658
Practice Address - Fax:813-681-5250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267292800Medicaid
FL34562Medicare ID - Type UnspecifiedFLORIDA MEDICARE