Healthcare Provider Details

I. General information

NPI: 1386890721
Provider Name (Legal Business Name): KISSIMMEE MEDICAL SPECIALTIES P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E OAK ST SUITE A
KISSIMMEE FL
34744-4575
US

IV. Provider business mailing address

701 E OAK ST SUITE A
KISSIMMEE FL
34744-4575
US

V. Phone/Fax

Practice location:
  • Phone: 407-944-0277
  • Fax: 407-870-9277
Mailing address:
  • Phone: 407-944-0277
  • Fax: 407-870-9277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberM37804
License Number StateFL

VIII. Authorized Official

Name: MS. YOLANDA PEREZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 407-944-0277