MEDICARE: AGE REJUVENATION MEDICAL, P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	133VN1201X	Obesity and Weight Management Nutrition Registered Dietitian
2	207QB0002X	Obesity Medicine (Family Medicine) Physician
3	2083B0002X	Obesity Medicine (Preventive Medicine) Physician
4	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1801603717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGE REJUVENATION MEDICAL, P.A.

Provider Business Mailing Address
First Line	:	2409 N FALKENBURG RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33619-0915
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 N ORLANDO AVE STE 115
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-3605
Country	:	US
Telephone Number	:	407-565-5929
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	YAZMYNE MIRANDA
Credential	:
Telephone Number	:	954-682-3015

Provider Enumeration Date	:	12/13/2024
Last Update Date	:	01/20/2025

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