Provider Demographics
NPI:1588153647
Name:DECLET-BAUZO, RICARDO ANDRE (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:ANDRE
Last Name:DECLET-BAUZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 W CARMEN ST APT 319
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-1302
Mailing Address - Country:US
Mailing Address - Phone:787-608-2600
Mailing Address - Fax:
Practice Address - Street 1:2330 UTAH AVE STE 200
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-4817
Practice Address - Country:US
Practice Address - Phone:281-766-0959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-04
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1662922085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology