Basic Information
| Provider Information | |||||||||
| NPI: | 1174899165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOANG | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | LENA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSENBERG | ||||||||
| OtherFirstName: | JESSIE | ||||||||
| OtherMiddleName: | LENA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 601 5TH S S, | ||||||||
| Address2: | DEPT #6500002705 | ||||||||
| City: | ST. PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277673051 | ||||||||
| FaxNumber: | 7277674970 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 S TAMIAMI TRAIL | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342390000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9419177490 | ||||||||
| FaxNumber: | 9419171308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2012 | ||||||||
| LastUpdateDate: | 09/02/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME123520 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 015605500 | 05 | FL | MEDICAID |