Healthcare Provider Details

I. General information

NPI: 1962434712
Provider Name (Legal Business Name): ROBERT G MUTCH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 E ALTAMONTE DR STE 328
ALTAMONTE SPRINGS FL
32701
US

IV. Provider business mailing address

661 E ALTAMONTE DR STE 328
ALTAMONTE SPRINGS FL
32701-5103
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-5204
  • Fax: 407-303-5205
Mailing address:
  • Phone: 407-303-5204
  • Fax: 407-303-5205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS16256
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101013139
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: