1033503099 NPI number — OPTUMCARE FLORIDA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033503099 NPI number — OPTUMCARE FLORIDA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTUMCARE FLORIDA, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DAVITA MEDICAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033503099
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10051 5TH STREET N.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST. PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1345 W BAY DR
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33770-2282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-559-0895
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LIETHEN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
952-205-6262

Provider Taxonomy Codes

  • Taxonomy code: 332900000X , with the licence number:  ME86502 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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