Healthcare Provider Details

I. General information

NPI: 1184266082
Provider Name (Legal Business Name): JULIANA ESCOBAR RESTREPO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 SAND MINE RD
DAVENPORT FL
33897-3402
US

IV. Provider business mailing address

PO BOX 1020
DAVENPORT FL
33836-1020
US

V. Phone/Fax

Practice location:
  • Phone: 863-419-7645
  • Fax:
Mailing address:
  • Phone: 718-219-3356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberPA9112759
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: