Provider Demographics
NPI:1427061043
Name:HOLMSTROM, SHELLY WELCH (MD)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:WELCH
Last Name:HOLMSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 HARBOUR WALK RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5971
Mailing Address - Country:US
Mailing Address - Phone:813-394-1668
Mailing Address - Fax:
Practice Address - Street 1:4503 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-6201
Practice Address - Country:US
Practice Address - Phone:813-738-6684
Practice Address - Fax:813-413-8549
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90448207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270375100Medicaid
FL48546OtherBLUE CROSS BLUE SHIELD
FL48546OtherBLUE CROSS BLUE SHIELD