Provider Demographics
NPI:1982637195
Name:INFECTIOUS DISEASE CONSULTANTS OF ST. PETERSBURG, P.A.
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE CONSULTANTS OF ST. PETERSBURG, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-845-4572
Mailing Address - Street 1:4604 29TH ST E
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-9793
Mailing Address - Country:US
Mailing Address - Phone:941-845-4572
Mailing Address - Fax:941-845-4572
Practice Address - Street 1:4604 29TH ST E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-9793
Practice Address - Country:US
Practice Address - Phone:941-845-4572
Practice Address - Fax:941-845-4572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5600211OtherGHI
FL34252OtherBLUE CROSS/BLUE SHIELD FL
CB6866OtherRAILROAD MEDICARE
FL263649200Medicaid
FL34252OtherBLUE CROSS/BLUE SHIELD FL