Provider Demographics
NPI:1235120122
Name:FERDERIGOS, FANOURIOS IACOVOS (MD)
Entity Type:Individual
Prefix:DR
First Name:FANOURIOS
Middle Name:IACOVOS
Last Name:FERDERIGOS
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 1:2626 TAMPA RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3155
Mailing Address - Country:US
Mailing Address - Phone:727-789-3300
Mailing Address - Fax:727-787-3454
Practice Address - Street 1:2626 TAMPA RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3155
Practice Address - Country:US
Practice Address - Phone:727-789-3300
Practice Address - Fax:727-787-3454
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40703207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02051OtherWELLCARE PROVIDER NUMBER
FL15800ZOtherMEDICARE PTAN
FL220139000OtherFEDERAL WORKERS COMP PROV
FL207845OtherAVMED PROVIDER NUMBER
FL592745575001OtherCHAMPUS PROVIDER NUMBER
FL1573201020OtherCIGNA PROVIDER NUMBER
FL624281OtherAETNA HMO
FL10015687OtherRAILROAD MEDICARE
FL4133544OtherAETNA PPO
FL02051OtherWELLCARE PROVIDER NUMBER
FL1573201020OtherCIGNA PROVIDER NUMBER