Basic Information
| Provider Information | |||||||||
| NPI: | 1174971683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORLANDO FAMILY PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S ORANGE AVE | ||||||||
| Address2: | SUITE 940 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213326947 | ||||||||
| FaxNumber: | 4076589688 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 N NOWELL ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328087539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072909556 | ||||||||
| FaxNumber: | 4072909509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2016 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | DWIGHT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3213326947 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORLANDO FAMILY PHYSICIANS, LLC | ||||||||
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| 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 | 101312509 | 05 | FL | MEDICAID |