Unknown Individual – Family Medicine Physician, NPI 1124058730

Unknown Individual is a healthcare provider. based in Brandon, Florida. specializing in Family Medicine Physician. They hold a License No. ME53171 (FL). The NPI Number for Unknown Individual is 1124058730

Main info

Organization
Inactive
41 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1124058730
Phone
(813) 681-5571
Address
206 E BRANDON BLVD
Deactivation Date
20 January 2021

Doctor Profile

Medical School Name
OTHER
Secondary Phone
7278637150
Graduation Year
1985 (41 years ago)
PAC ID
2860392446
Group Practice PAC ID
3779573167
Professional Enrollment ID
I20131114001665
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience23
Completeness75
Years active:0State licenses:2Digital endpointsOther names

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Provider Addresses for Unknown Individual

  • 206, East Brandon Boulevard, Brandon, Hillsborough County, Florida, 33511, United States

    BRANDON, FL 335115221

    Phone: (813) 681-5571

    Fax: (813) 689-8128

    Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 33511)

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Provider's Procedures

Unknown Individual performs procedures in Family Medicine Physician. See the list of HCPCS codes below.
SpecialtyPractice State
HCPCS Code
Description
Service Count
Beneficiary Count
FAMILY MEDICINEFL73630X-ray of foot, minimum of 3 views1111

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 3779573167View full group profile
NameSpecialtyState
CHRISTOPHER ROBERT BACKSMAN (APRN)
-FL
MICHELLE F DUBUISSON (FNP-C)
-TN
JENIFER L GROOMS (CRNP, APRN)
Nurse PractitionerFL
DR. JAMES P DAVISON (D.O)
-FL
DR. RAVINDRA VAJJHALA (MD)
-PA
MRS. SIMONE MUKNICKA LOWERY (PA-C)
-FL
MICHAEL B WHITE (M.D.)
-FL
JOSE M ALMANZAR (PA-C)
Physician AssistantFL
LATISA TIANA LYNCH (ARNP)
Nurse PractitionerFL
KANDI MARI HEATH (RN-FNP)
Nurse PractitionerFL

Reviews

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Frequently asked questions

What number should I use to identify Unknown Individual for billing?
Administrative and clinical systems typically use NPI 1124058730 for Unknown Individual.
Does inactive mean outdated data for Unknown Individual?
Inactive status means the NPI record is not marked active in the public file — verify before making care decisions.
How should patients interpret Unknown Individual's specialty?
The extract shows Family Medicine Physician for Unknown Individual. Clinical services aligned with this taxonomy classification.
Is Unknown Individual tied to Brandon, Florida?
If you are local to Brandon, Florida, Unknown Individual may be relevant to your search.
Why is information missing for Unknown Individual?
Providers choose how much contact data to publish. Missing fields do not mean the profile is fake.