Provider Demographics
NPI:1053188417
Name:ENDOONE DIABETES & ENDOCRINOLOGY CENTER, LLC
Entity type:Organization
Organization Name:ENDOONE DIABETES & ENDOCRINOLOGY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:MEYRELES CHALJUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-931-2424
Mailing Address - Street 1:602 S AUDUBON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 S AUDUBON AVE STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4217
Practice Address - Country:US
Practice Address - Phone:813-931-2424
Practice Address - Fax:813-869-3148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-06
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121617900Medicaid