Provider Demographics
NPI:1982627774
Name:FOSSI, CARLOS ENRIQUE (M,D)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ENRIQUE
Last Name:FOSSI
Suffix:
Gender:M
Credentials:M,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 KINGSWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3026
Mailing Address - Country:US
Mailing Address - Phone:863-274-0853
Mailing Address - Fax:863-582-9436
Practice Address - Street 1:5030 KINGSWOOD DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3026
Practice Address - Country:US
Practice Address - Phone:863-274-0853
Practice Address - Fax:863-582-9436
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51410261QU0200X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0644056-00Medicaid
FLE66587Medicare UPIN
FL0644056-00Medicaid