Provider Demographics
NPI:1780950212
Name:LEONCIO TACSA CARRASCO MD PLLC
Entity type:Organization
Organization Name:LEONCIO TACSA CARRASCO MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:LEONCIO
Authorized Official - Middle Name:
Authorized Official - Last Name:TACSA CARRASCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-894-6703
Mailing Address - Street 1:1111 7TH AVE N
Mailing Address - Street 2:STE 107
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1348
Mailing Address - Country:US
Mailing Address - Phone:727-894-6703
Mailing Address - Fax:727-894-1430
Practice Address - Street 1:1111 7TH AVE N
Practice Address - Street 2:STE 107
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1348
Practice Address - Country:US
Practice Address - Phone:727-894-6703
Practice Address - Fax:727-894-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72300207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC1947ZMedicare PIN