Provider Demographics
NPI:1750975751
Name:MBOM, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MBOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DAVIS BLVD STE 504
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3475
Mailing Address - Country:US
Mailing Address - Phone:813-259-8783
Mailing Address - Fax:
Practice Address - Street 1:17 DAVIS BLVD STE 504
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3475
Practice Address - Country:US
Practice Address - Phone:813-259-8783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME167354207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS49789OtherPHARMACIST LICENSE