Provider Demographics
NPI:1285196956
Name:IN HOME PODIATRY SC
Entity Type:Organization
Organization Name:IN HOME PODIATRY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIBIBI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-525-6135
Mailing Address - Street 1:7532 CLEARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-2930
Mailing Address - Country:US
Mailing Address - Phone:813-525-6135
Mailing Address - Fax:
Practice Address - Street 1:7532 CLEARVIEW DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-2930
Practice Address - Country:US
Practice Address - Phone:813-525-6135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-02
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO4035OtherPODIATRIC LICENSE