Provider Demographics
NPI:1770593923
Name:MOSS GRIZZARD, KATHLEEN M (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:MOSS GRIZZARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4108 HENDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5750
Mailing Address - Country:US
Mailing Address - Phone:813-289-4321
Mailing Address - Fax:813-287-2949
Practice Address - Street 1:4108 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5750
Practice Address - Country:US
Practice Address - Phone:813-289-4321
Practice Address - Fax:813-287-2949
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME33818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110178342OtherRAILROAD
FL00004389OtherUNITED
FL30475OtherBCBS
FL30475OtherBCBS
FLD54008Medicare UPIN