Healthcare Provider Details

I. General information

NPI: 1336356492
Provider Name (Legal Business Name): THE FAMILY PHYSICIAN OF BVL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 MICHIGAN AVE
KISSIMMEE FL
34744-1501
US

IV. Provider business mailing address

3071 MICHIGAN AVE
KISSIMMEE FL
34744-1501
US

V. Phone/Fax

Practice location:
  • Phone: 407-348-9111
  • Fax: 407-348-9112
Mailing address:
  • Phone: 407-348-9111
  • Fax: 407-348-9112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberME62672
License Number StateFL

VIII. Authorized Official

Name: DR. FAUSTO RONALD BURGOS
Title or Position: PHYSICAN
Credential: MD
Phone: 407-348-9111