Provider Demographics
NPI:1821585431
Name:GONTA, ROMAN
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:GONTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ROMAN
Other - Middle Name:
Other - Last Name:KHAMITOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 198441
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8441
Mailing Address - Country:US
Mailing Address - Phone:813-745-7365
Mailing Address - Fax:813-449-8618
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-7365
Practice Address - Fax:813-449-8618
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME169515207ZH0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program