Basic Information
| Provider Information | |||||||||
| NPI: | 1740268929 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINTER PARK FAMILY PRACTICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21406 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336221406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
| FaxNumber: | 7278280723 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S ORLANDO AVE | ||||||||
| Address2: | STE 204 | ||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327895543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076474008 | ||||||||
| FaxNumber: | 4076473207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 12/05/2013 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | VARESH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7278232188 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DQ6581 | 01 | FL | RAILROAD MEDICARE | OTHER |