Provider Demographics
NPI:1669745162
Name:BONITA J DRAKE M.D, P.A
Entity type:Organization
Organization Name:BONITA J DRAKE M.D, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BONITA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-821-0612
Mailing Address - Street 1:3950 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-6123
Mailing Address - Country:US
Mailing Address - Phone:727-821-0612
Mailing Address - Fax:727-822-5507
Practice Address - Street 1:3950 3RD ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-6123
Practice Address - Country:US
Practice Address - Phone:727-821-0612
Practice Address - Fax:727-822-5507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME15815207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL78011Medicare PIN