Provider Demographics
NPI:1154700276
Name:TOTAL VITALITY MEDICAL GROUP
Entity type:Organization
Organization Name:TOTAL VITALITY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISPENSING PRACTITONER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-283-1910
Mailing Address - Street 1:311 PARK PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:813-867-7201
Mailing Address - Fax:
Practice Address - Street 1:4100 W KENNEDY BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2288
Practice Address - Country:US
Practice Address - Phone:813-283-1910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME17577332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site