Provider Demographics
NPI:1780171793
Name:LEBOUTILLIER, ROSHNI MARBALLI (DO)
Entity type:Individual
Prefix:
First Name:ROSHNI
Middle Name:MARBALLI
Last Name:LEBOUTILLIER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 SUNFOREST DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6327
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:727-568-6011
Practice Address - Street 1:8342 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-8653
Practice Address - Country:US
Practice Address - Phone:941-729-4400
Practice Address - Fax:941-729-4424
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLOS17920207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program