Provider Demographics
NPI:1467859660
Name:NODAL, OSVANNY (MD)
Entity Type:Individual
Prefix:
First Name:OSVANNY
Middle Name:
Last Name:NODAL
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 1:2123 W DR MARTIN LUTHER KING JR BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6545
Mailing Address - Country:US
Mailing Address - Phone:813-235-5068
Mailing Address - Fax:
Practice Address - Street 1:2123 WEST MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607
Practice Address - Country:US
Practice Address - Phone:813-488-4801
Practice Address - Fax:813-405-4506
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18,942208D00000X
FLACN693208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice