Basic Information
Provider Information | |||||||||
NPI: | 1013318625 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORLANDO FAMILY PHYSICIANS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 121 S ORANGE AVE | ||||||||
Address2: | SUITE 940N | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328013221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3213326947 | ||||||||
FaxNumber: | 4076589688 | ||||||||
Practice Location | |||||||||
Address1: | 1130 S SEMORAN BLVD | ||||||||
Address2: | SUITES B & C | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328071457 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073821376 | ||||||||
FaxNumber: | 3212353232 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2014 | ||||||||
LastUpdateDate: | 06/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEREZ | ||||||||
AuthorizedOfficialFirstName: | DWIGHT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3213326947 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X |   |   | Y |   | Suppliers | Non-Pharmacy Dispensing Site |   |
ID Information
ID | Type | State | Issuer | Description | 101312506 | 05 | FL |   | MEDICAID |