Provider Demographics
NPI:1558433359
Name:FIALLOS, YANINA J (MD)
Entity Type:Individual
Prefix:
First Name:YANINA
Middle Name:J
Last Name:FIALLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17541 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4521
Mailing Address - Country:US
Mailing Address - Phone:813-964-1800
Mailing Address - Fax:813-964-1880
Practice Address - Street 1:17541 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4521
Practice Address - Country:US
Practice Address - Phone:813-964-1800
Practice Address - Fax:813-964-1880
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69011208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123078OtherHUMANA
FL251448600Medicaid
FL32240OtherBLUE CROSS
G33556Medicare UPIN