1225457484 NPI number — DR. DAISSY CAROLINA MCENNAN M.D.

Table of content: DR. DAISSY CAROLINA MCENNAN M.D. (NPI 1225457484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225457484 NPI number — DR. DAISSY CAROLINA MCENNAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCENNAN
Provider First Name:
DAISSY
Provider Middle Name:
CAROLINA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOMINGUEZ MARQUEZ
Provider Other First Name:
DAISSY
Provider Other Middle Name:
CAROLINA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225457484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 DAVIS BLVD
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33606-3475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-250-2506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 DAVIS BLVD
Provider Second Line Business Practice Location Address:
SUITE 308
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-396-2515
Provider Business Practice Location Address Fax Number:
813-905-9896
Provider Enumeration Date:
04/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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