Basic Information
| Provider Information | |||||||||
| NPI: | 1720680887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON PEREZ MENA | ||||||||
| FirstName: | ELISA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| 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: | 810 N NOWELL ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328087539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072909556 | ||||||||
| FaxNumber: | 4076306884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2020 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | ACN1296 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.