Provider Demographics
NPI:1659672236
Name:VIJAY DIWADKAR,M.D.PA
Entity Type:Organization
Organization Name:VIJAY DIWADKAR,M.D.PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIWADKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-237-2500
Mailing Address - Street 1:701 W M.L.KING BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-1922
Mailing Address - Country:US
Mailing Address - Phone:813-237-2500
Mailing Address - Fax:813-237-2871
Practice Address - Street 1:701 W M.L.KING JR. BLVD.
Practice Address - Street 2:SUITE 3
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-3100
Practice Address - Country:US
Practice Address - Phone:813-237-2500
Practice Address - Fax:813-237-2871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39294207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30476OtherBCBS
FL066699800Medicaid
FL066699800Medicaid
FL30476Medicare PIN