Provider Demographics
NPI:1629133764
Name:SIFONTES, OLIVIA JOSEFINA (ITDS)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JOSEFINA
Last Name:SIFONTES
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 W DR MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7011
Mailing Address - Country:US
Mailing Address - Phone:813-876-1605
Mailing Address - Fax:813-876-1620
Practice Address - Street 1:4001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7011
Practice Address - Country:US
Practice Address - Phone:813-876-1605
Practice Address - Fax:813-876-1620
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist