Basic Information
| Provider Information | |||||||||
| NPI: | 1316294259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARRION-ROMAN | ||||||||
| FirstName: | ODALYS | ||||||||
| MiddleName: | WITNELIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6900 TAVISTOCK LAKES BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328277592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213326947 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 920 N JOHN YOUNG PKWY | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079869642 | ||||||||
| FaxNumber: | 4075936102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2012 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 18362 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN1052 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.