Provider Demographics
NPI:1386999589
Name:JUAN C BAYOLO MD LLC
Entity type:Organization
Organization Name:JUAN C BAYOLO MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPIETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:BAYOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-605-0662
Mailing Address - Street 1:3430 W LAMBRIGHT ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-4750
Mailing Address - Country:US
Mailing Address - Phone:813-605-0662
Mailing Address - Fax:813-605-0663
Practice Address - Street 1:3430 W LAMBRIGHT ST
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-4750
Practice Address - Country:US
Practice Address - Phone:813-605-0662
Practice Address - Fax:813-605-0663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN247261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278268500Medicaid
FL1801848478OtherNPI