Basic Information
| Provider Information | |||||||||
| NPI: | 1962665646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERCEVAL | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9400 TURKEY LAKE RD | ||||||||
| Address2: | MP 452 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218435500 | ||||||||
| FaxNumber: | 3218435550 | ||||||||
| Practice Location | |||||||||
| Address1: | 9400 TURKEY LAKE RD | ||||||||
| Address2: | MP 452 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328198001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218435500 | ||||||||
| FaxNumber: | 3218435550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | ME101573 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | ME101573 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000353100 | 05 | FL | MEDICAID | ME101573 | 01 | FL | LICENSE | OTHER |