Provider Demographics
NPI:1265054803
Name:WATERS EDGE MEDICAL CLINIC TAMPA LLC
Entity type:Organization
Organization Name:WATERS EDGE MEDICAL CLINIC TAMPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VODOPALAS-PUODZIUNAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-603-9683
Mailing Address - Street 1:1700 66TH ST N STE 304
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5500
Mailing Address - Country:US
Mailing Address - Phone:727-550-0855
Mailing Address - Fax:727-205-8159
Practice Address - Street 1:1700 66TH ST N STE 304
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5500
Practice Address - Country:US
Practice Address - Phone:727-550-0855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-16
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care