Provider Demographics
NPI:1376675454
Name:ANTONIO PRADO MD PA
Entity type:Organization
Organization Name:ANTONIO PRADO MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PRADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-931-0500
Mailing Address - Street 1:7522 N HIMES AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-3205
Mailing Address - Country:US
Mailing Address - Phone:813-931-0500
Mailing Address - Fax:
Practice Address - Street 1:7522 N HIMES AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3205
Practice Address - Country:US
Practice Address - Phone:813-931-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64750207W00000X
332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277042300Medicaid
FL99062OtherBLUE CROSS BLUE SHIELD FL
FL4040770001Medicare NSC
FL99062OtherBLUE CROSS BLUE SHIELD FL