Provider Demographics
NPI:1164766002
Name:JOSE R. FORADADA, III, MD, P.A.
Entity Type:Organization
Organization Name:JOSE R. FORADADA, III, MD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:RAMON
Authorized Official - Last Name:FORADADA
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:813-874-2000
Mailing Address - Street 1:4710 N. HABANA AVE.
Mailing Address - Street 2:SUITE 307
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7151
Mailing Address - Country:US
Mailing Address - Phone:813-874-2000
Mailing Address - Fax:813-874-9303
Practice Address - Street 1:4710 N. HABANA AVE.
Practice Address - Street 2:SUITE 307
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7151
Practice Address - Country:US
Practice Address - Phone:813-874-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00568852084N0402X
FLARNP3390982363LP0200X
FLARNP9263175363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273113400OtherMEDICAID GROUP
FL062490000Medicaid
FL09957AMedicare PIN
FL273113400OtherMEDICAID GROUP