Provider Demographics
NPI:1528364882
Name:DOCTORS MEDICAL CLINICS OF TAMPA, LLC
Entity Type:Organization
Organization Name:DOCTORS MEDICAL CLINICS OF TAMPA, LLC
Other - Org Name:DOCTORS MEDICAL CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WISDOM
Authorized Official - Middle Name:K
Authorized Official - Last Name:DARKO
Authorized Official - Suffix:
Authorized Official - Credentials:HRM
Authorized Official - Phone:813-988-8380
Mailing Address - Street 1:10770 N 46TH ST STE B300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-3488
Mailing Address - Country:US
Mailing Address - Phone:813-988-8380
Mailing Address - Fax:813-988-8423
Practice Address - Street 1:10770 N 46TH ST STE B300
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-3488
Practice Address - Country:US
Practice Address - Phone:813-988-8380
Practice Address - Fax:813-988-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8997261Q00000X, 302R00000X
FLPMC1035261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC8997OtherAHCA
FLEZ293AOtherMEDICARE