Provider Demographics
NPI:1497844120
Name:KUTOB, TARIQ (MD)
Entity type:Individual
Prefix:
First Name:TARIQ
Middle Name:
Last Name:KUTOB
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 66TH ST N STE 101
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-2101
Mailing Address - Country:US
Mailing Address - Phone:727-546-5702
Mailing Address - Fax:727-546-5700
Practice Address - Street 1:7800 66TH ST N STE 101
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2101
Practice Address - Country:US
Practice Address - Phone:727-546-5702
Practice Address - Fax:727-546-5700
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060391207Q00000X
FLME156735207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115027600Medicaid
FLME156735OtherFLORIDA MEDICAL LICENSE
MI4301060391OtherBOARD OF MEDICINE LICENSE