Provider Demographics
NPI:1922102078
Name:FLORIDA DIGESTIVE SPECIALISTS, PA
Entity Type:Organization
Organization Name:FLORIDA DIGESTIVE SPECIALISTS, PA
Other - Org Name:FLORIDA DIGESTIVE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:IVELISS
Authorized Official - Middle Name:
Authorized Official - Last Name:VIERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-443-4299
Mailing Address - Street 1:5651 49TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2105
Mailing Address - Country:US
Mailing Address - Phone:727-443-4299
Mailing Address - Fax:727-443-0255
Practice Address - Street 1:5651 49TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2105
Practice Address - Country:US
Practice Address - Phone:727-443-4299
Practice Address - Fax:727-443-0255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36704174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060540900Medicaid
FL060540900Medicaid