Provider Demographics
NPI:1518031434
Name:SIORES, FREDERIC C (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:C
Last Name:SIORES
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 1:10011 WALTZING LN
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-3434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2298
Practice Address - Country:US
Practice Address - Phone:727-581-8767
Practice Address - Fax:727-559-0594
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME826632085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262919400Medicaid
FL25006ZMedicare ID - Type Unspecified