Provider Demographics
NPI:1992795587
Name:TAGALA, ROMEO ADANO (MD)
Entity type:Individual
Prefix:
First Name:ROMEO
Middle Name:ADANO
Last Name:TAGALA
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 1:3885 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-1109
Mailing Address - Country:US
Mailing Address - Phone:863-644-6608
Mailing Address - Fax:863-644-0147
Practice Address - Street 1:3885 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1109
Practice Address - Country:US
Practice Address - Phone:863-644-6608
Practice Address - Fax:863-644-0147
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33472208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL53592OtherBC FL
FL066847800Medicaid
P00870043OtherRAILROAD MC
D56601Medicare UPIN
FL53592ZMedicare PIN