Basic Information
Provider Information
NPI: 1487215976
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: POLITE
FirstName: AYENDI
MiddleName: C
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7108 S KANNER HWY
Address2:  
City: STUART
State: FL
PostalCode: 349977462
CountryCode: US
TelephoneNumber:  
FaxNumber: 8134404916
Practice Location
Address1: 907 OUTER RD STE B
Address2:  
City: ORLANDO
State: FL
PostalCode: 328146601
CountryCode: US
TelephoneNumber: 8558326727
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/25/2019
LastUpdateDate: 06/07/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 06/07/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  N    
106E00000X FLY    

ID Information
IDTypeStateIssuerDescription
10536450005FL MEDICAID


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