1124026117 NPI number — GERARDO ANTONIO PEDROZA-SIERRA M.D.

Table of content: GERARDO ANTONIO PEDROZA-SIERRA M.D. (NPI 1124026117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124026117 NPI number — GERARDO ANTONIO PEDROZA-SIERRA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEDROZA-SIERRA
Provider First Name:
GERARDO
Provider Middle Name:
ANTONIO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1124026117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 S HARBOUR ISLAND BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33602-5925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-322-3439
Provider Business Mailing Address Fax Number:
800-928-7449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6090 26TH ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34207-4401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-218-2353
Provider Business Practice Location Address Fax Number:
844-388-6186
Provider Enumeration Date:
07/13/2005

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: 208D00000X , with the licence number:  15516 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: ACN631 , 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: 9120272 . This is a "HUMANA HEALTH PLAN" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 9120272 . This is a "HUMANA INSURANCE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: 9120272 . This is a "HUMANA GOLD CHOICE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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