Provider Demographics
NPI:1134146673
Name:LIBERATO, TANYA MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:MICHELLE
Last Name:LIBERATO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TANYA
Other - Middle Name:M
Other - Last Name:HARKESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4033 TAMPA RD
Mailing Address - Street 2:STE.101
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3224
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-855-2367
Practice Address - Street 1:10729 QUEENS TOWN DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-7186
Practice Address - Country:US
Practice Address - Phone:813-672-3497
Practice Address - Fax:813-741-2418
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0079054208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL259128600Medicaid
FL259128600Medicaid
E6782ZMedicare ID - Type Unspecified