Healthcare Provider Details

I. General information

NPI: 1275178691
Provider Name (Legal Business Name): MR. MATTHEW BERWAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 OCOEE APOPKA RD STE 120
APOPKA FL
32703-9210
US

IV. Provider business mailing address

2100 OCOEE APOPKA RD STE 120
APOPKA FL
32703-9210
US

V. Phone/Fax

Practice location:
  • Phone: 407-889-1930
  • Fax:
Mailing address:
  • Phone: 407-889-1930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112907
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: