Provider Demographics
NPI:1932346392
Name:MEDERO MEDICAL OF TAMPA WEST
Entity Type:Organization
Organization Name:MEDERO MEDICAL OF TAMPA WEST
Other - Org Name:MEDERO MEDICAL TAMPA WEST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-629-3433
Mailing Address - Street 1:5406 HOOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-5330
Mailing Address - Country:US
Mailing Address - Phone:352-629-3433
Mailing Address - Fax:352-629-6796
Practice Address - Street 1:1109 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-0325
Practice Address - Country:US
Practice Address - Phone:352-629-3433
Practice Address - Fax:352-629-6796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL129742083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty