Provider Demographics
NPI:1457309692
Name:ENTZIAN, DIRK (MD)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:
Last Name:ENTZIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SOUTH ASHLEY DRIVE
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5318
Mailing Address - Country:US
Mailing Address - Phone:813-899-6220
Mailing Address - Fax:813-985-8006
Practice Address - Street 1:100 SOUTH ASHLEY DRIVE
Practice Address - Street 2:SUITE 1500
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-5318
Practice Address - Country:US
Practice Address - Phone:813-899-6220
Practice Address - Fax:813-985-8006
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0501602085R0202X, 2085R0204X
IDM-115662085R0202X
UT8048800-12052085R0202X
FLME1265982085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000075283OtherMEDICARE
ID20000820OtherMEDICARE
ID20000820OtherMEDICARE