Basic Information
Provider Information | |||||||||
NPI: | 1659949592 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORLANDO FAMILY PHYSICIANS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 121 S ORANGE AVE STE 940 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328013234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3213326947 | ||||||||
FaxNumber: | 4072864515 | ||||||||
Practice Location | |||||||||
Address1: | 1502 VILLAGE OAK LN | ||||||||
Address2: |   | ||||||||
City: | KISSIMMEE | ||||||||
State: | FL | ||||||||
PostalCode: | 347466558 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075203588 | ||||||||
FaxNumber: | 4079786757 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2021 | ||||||||
LastUpdateDate: | 06/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PEREZ | ||||||||
AuthorizedOfficialFirstName: | DWIGHT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 3213326947 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ORLANDO FAMILY PHYSICIANS, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 208D00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 101312518 | 05 | FL |   | MEDICAID |