Provider Demographics
NPI:1710461553
Name:PEDROSO, VERONICA
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:PEDROSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 BAYSHORE BLVD UNIT 609
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3189
Mailing Address - Country:US
Mailing Address - Phone:727-945-2830
Mailing Address - Fax:
Practice Address - Street 1:7045 EVERGREEN WOODS TRL
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-1306
Practice Address - Country:US
Practice Address - Phone:352-596-8371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25247225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000000000000Medicaid