Provider Demographics
NPI: | 1750669032 |
---|---|
Name: | MITSOPOULOS, GUS (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | GUS |
Middle Name: | |
Last Name: | MITSOPOULOS |
Suffix: | |
Gender: | M |
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: | 100 SOUTH ASHLEY DRIVE |
Mailing Address - Street 2: | SUITE 1500 |
Mailing Address - City: | TAMPA |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33602-5318 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 813-899-6220 |
Mailing Address - Fax: | 813-985-8006 |
Practice Address - Street 1: | 100 SOUTH ASHLEY DRIVE |
Practice Address - Street 2: | SUITE 1500 |
Practice Address - City: | TAMPA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33602-5318 |
Practice Address - Country: | US |
Practice Address - Phone: | 813-899-6220 |
Practice Address - Fax: | 813-985-8006 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-08-03 |
Last Update Date: | 2015-07-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME119893 | 2085R0204X, 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 012467100 | Medicaid | |
FL | 012467100 | Medicaid |