Basic Information
Provider Information | |||||||||
NPI: | 1598840076 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AYERS | ||||||||
FirstName: | GWEN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILCOX | ||||||||
OtherFirstName: | GWEN | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 13000 BRUCE B DOWNS BLVD | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336124745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139722000 | ||||||||
FaxNumber: | 8139793628 | ||||||||
Practice Location | |||||||||
Address1: | 13000 BRUCE B DOWNS BLVD | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336124745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139722000 | ||||||||
FaxNumber: | 8139793628 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2006 | ||||||||
LastUpdateDate: | 05/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | ME139064 | FL | Y |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 2085R0202X | 30850 | TN | N |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 110216700 | 05 | FL |   | MEDICAID |