Healthcare Provider Details

I. General information

NPI: 1972607349
Provider Name (Legal Business Name): MARIA LOURDES P BURGOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MA LOURDES P BURGOS MD

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 01/27/2012
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 NumberME0054370
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME54370
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: