1851589030 NPI number — DEVAN C. WALICEK ARNP

Table of content: DEVAN C. WALICEK ARNP (NPI 1851589030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851589030 NPI number — DEVAN C. WALICEK ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALICEK
Provider First Name:
DEVAN
Provider Middle Name:
C.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

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:
1851589030
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4033 TAMPA RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
OLDSMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34677-3224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-854-2003
Provider Business Mailing Address Fax Number:
813-855-2367

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3222 W AZEELE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33609-3280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-872-8491
Provider Business Practice Location Address Fax Number:
813-872-7766
Provider Enumeration Date:
10/12/2007

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: 363LP0200X , with the licence number:  ARNP 9252149 , 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: 014962500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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