Basic Information
| Provider Information | |||||||||
| NPI: | 1285151498 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEZA | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DPT, PT, ATC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11058 FAIRHAVEN WAY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328257110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018707879 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3451 TECHNOLOGICAL AVE | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328178353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076812520 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2017 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 38355 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | 4267 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | 38355 | 01 | FL | PHYSICAL THERAPY | OTHER | 4267 | 01 | FL | ATHLETIC TRAINING LICENSE | OTHER |