Provider Demographics
NPI:1508016320
Name:CEBALLOS, SERGIO ROBERTO (LMT)
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:ROBERTO
Last Name:CEBALLOS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7506 COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1546
Mailing Address - Country:US
Mailing Address - Phone:813-480-5046
Mailing Address - Fax:
Practice Address - Street 1:6506 N FLORIDA AVE
Practice Address - Street 2:STE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-6060
Practice Address - Country:US
Practice Address - Phone:813-964-6872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA54554247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other