1487631065 NPI number — ROBERT E CREIGHTON D.P.M.

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 1487631065 NPI number — ROBERT E CREIGHTON D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CREIGHTON
Provider First Name:
ROBERT
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1487631065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2835 W DE LEON ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33609-4168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-254-6592
Provider Business Mailing Address Fax Number:
813-254-3634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3491 GANDY BLVD N STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINELLAS PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33781-2652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-384-5540
Provider Business Practice Location Address Fax Number:
727-384-5520
Provider Enumeration Date:
12/27/2005

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: 213E00000X , with the licence number:  PO0002015 , 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)

  • Identifier: 2700457 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 65137 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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