Basic Information
| Provider Information | |||||||||
| NPI: | 1013516061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAMAYO DURUTY | ||||||||
| FirstName: | GIDER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3907 GANDER CT | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328227714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075586040 | ||||||||
| FaxNumber: | 4073867454 | ||||||||
| Practice Location | |||||||||
| Address1: | 5575 S SEMORAN BLVD STE 7 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328221781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214005254 | ||||||||
| FaxNumber: | 4073867454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2020 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 10723150 | 05 | FL | MEDICAID | 107231500 | 05 | FL | MEDICAID |