Provider Demographics
NPI:1043274079
Name:HOOPER, TIA LETRICIA (MD)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:LETRICIA
Last Name:HOOPER
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 1:16765 FISHHAWK BLVD
Mailing Address - Street 2:SUITE 314
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-3860
Mailing Address - Country:US
Mailing Address - Phone:813-961-1411
Mailing Address - Fax:813-671-1056
Practice Address - Street 1:10036 WATER WORKS LN
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5301
Practice Address - Country:US
Practice Address - Phone:813-961-1411
Practice Address - Fax:813-671-1056
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72164207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252666200Medicaid
FLE0221WMedicare PIN
FLE0221YMedicare PIN
FL252666200Medicaid