Healthcare Provider Details

I. General information

NPI: 1770044422
Provider Name (Legal Business Name): LUZ ELENIA GOYCO ORTIZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5167
US

IV. Provider business mailing address

5255 OFFICE PARK BLVD STE 110
BRADENTON FL
34203
US

V. Phone/Fax

Practice location:
  • Phone: 407-975-0410
  • Fax: 407-975-0407
Mailing address:
  • Phone: 941-755-7000
  • Fax: 941-755-7088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME156859
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: