Waters Edge Medical Clinic Tampa LLC

Primary specialty

Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X

Legal business name

WATERS EDGE MEDICAL CLINIC TAMPA LLC

Practice address

1700 66TH St N Ste 304
St Petersburg, FL 33710-5500

Phone

(727) 550-0855

NPI assigned

May 16, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Vida Vodopalas-Puodziunas, DCNPI 1528064110

Title

Owner

Phone

(815) 603-9683

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in FL2 enrollments

Enrollment records 2

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• Medical Home PL

  dba AllCare Clinic

  • Primary Care Clinic/Center
  • St Petersburg, FL
  • NPI 1629485271

  O20170725000218

  Same enrollment

Tax ID family

Allcare Clinic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Medical Home PL

  dba AllCare Clinic

  • Primary Care Clinic/Center
  • St Petersburg, FL
  • NPI 1629485271
  NPD tax ID

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Fred Elton Clark III, M.D.

  • Family Medicine Physician
  • St Petersburg, FL
  • NPI 1609022086
  Medicare reassignment NPD
• Vida Vodopalas-Puodziunas, D.C.

  • Chiropractor
  • St Petersburg, FL
  • NPI 1528064110
  NPD Authorized official
• Sarah Boyd, FNP-BC

  • Family Nurse Practitioner
  • St Petersburg, FL
  • NPI 1528896354
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1589587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1692748800000",
    "number": "1265054803",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1700 66TH ST N STE 304",
            "city": "ST PETERSBURG",
            "state": "FL",
            "postal_code": "337105500",
            "telephone_number": "727-550-0855",
            "fax_number": "727-205-8159"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1700 66TH ST N STE 304",
            "city": "ST PETERSBURG",
            "state": "FL",
            "postal_code": "337105500",
            "telephone_number": "727-550-0855"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WATERS EDGE MEDICAL CLINIC TAMPA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-05-16",
        "last_updated": "2023-08-23",
        "certification_date": "2023-08-23",
        "status": "A",
        "authorized_official_last_name": "VODOPALAS-PUODZIUNAS",
        "authorized_official_first_name": "VIDA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "815-603-9683",
        "authorized_official_credential": "DC"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kathleen M Wasylik, MD
• Water Glass Laboratories Tampa Bay LLC
• Watercolor Dental LLC
• Amy Kennedy Waterman, M.A. CCC SLP
• Kathryn M Waterman, RPA-C, MPAS
• Michele Waters Suro
• Alexis Waters Waters
• Demetric Watkins, LMHC
• Floyd L. Watkins
• Scott Christopher Watkins, MD

• Multi-Specialty Clinic/Center in St Petersburg, FL
• Providers in St Petersburg, FL by specialty
• Multi-Specialty Clinic/Center in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.