Provider Demographics
NPI:1518003623
Name:FIETSAM, ROBERT JR (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FIETSAM
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:6006 49TH ST N
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2148
Mailing Address - Country:US
Mailing Address - Phone:727-527-9779
Mailing Address - Fax:727-490-5043
Practice Address - Street 1:720 W OAK ST
Practice Address - Street 2:SUITE 360
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4989
Practice Address - Country:US
Practice Address - Phone:407-846-0090
Practice Address - Fax:407-846-0072
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2012-07-17
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Provider Licenses
StateLicense IDTaxonomies
FLME67888208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG05484Medicare UPIN