Provider Demographics
NPI:1487963864
Name:SPECIALIST DOCTORS GROUP LLC
Entity type:Organization
Organization Name:SPECIALIST DOCTORS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SALVATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-752-7222
Mailing Address - Street 1:P.O. BOX 770
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-0570
Mailing Address - Country:US
Mailing Address - Phone:813-719-3525
Mailing Address - Fax:813-719-3175
Practice Address - Street 1:210 N ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-4302
Practice Address - Country:US
Practice Address - Phone:813-752-7222
Practice Address - Fax:813-752-7255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL213ES0103X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty