Provider Demographics
NPI:1619187473
Name:TAMARA PISTORIA D.O.
Entity Type:Organization
Organization Name:TAMARA PISTORIA D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PISTORIA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:863-293-3909
Mailing Address - Street 1:400 AVENUE K SE
Mailing Address - Street 2:STE 5
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4146
Mailing Address - Country:US
Mailing Address - Phone:863-293-3909
Mailing Address - Fax:
Practice Address - Street 1:400 AVENUE K SE
Practice Address - Street 2:STE 5
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-4146
Practice Address - Country:US
Practice Address - Phone:863-293-3909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOF0008614208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264246800Medicaid
FLBP8045026OtherDEA
FL264246800Medicaid