Basic Information
| Provider Information | |||||||||
| NPI: | 1205817590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLD | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10051 5TH ST N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337022289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | 7275686011 | ||||||||
| Practice Location | |||||||||
| Address1: | 10051 5TH ST N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337022289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | 7275686011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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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 | 207Q00000X | ME91930 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 274427900 | 05 | FL | MEDICAID |