Provider Demographics
NPI:1932107158
Name:PISTORIA, TAMARA THRELKELD (DO)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:THRELKELD
Last Name:PISTORIA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95004
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-5004
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:863-680-7420
Practice Address - Street 1:1033 N PARKWAY FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-0401
Practice Address - Country:US
Practice Address - Phone:863-647-8011
Practice Address - Fax:863-647-8029
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0008614208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264246800Medicaid
FL264246800Medicaid