Healthcare Provider Details

I. General information

NPI: 1548646334
Provider Name (Legal Business Name): MARIA LOURDES P BURGOS , MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E ORANGE AVE
EUSTIS FL
32726-4248
US

IV. Provider business mailing address

820 E ORANGE AVE
EUSTIS FL
32726-4248
US

V. Phone/Fax

Practice location:
  • Phone: 352-589-1999
  • Fax: 352-589-5145
Mailing address:
  • Phone: 352-589-1999
  • Fax: 352-589-5145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 054370
License Number StateFL

VIII. Authorized Official

Name: DR. MARIA LOURDES P BURGOS
Title or Position: PHYSICIAN
Credential: MD
Phone: 352-255-3688