Healthcare Provider Details

I. General information

NPI: 1922039254
Provider Name (Legal Business Name): CENTERWELL SENIOR PRIMARY CARE (FL) INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904B CYPRESS PKWY
KISSIMMEE FL
34759-3456
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 200
MIAMI FL
33126-3168
US

V. Phone/Fax

Practice location:
  • Phone: 407-483-1400
  • Fax: 407-483-1405
Mailing address:
  • Phone: 305-500-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: ANGIE MARTINEZ
Title or Position: SENIOR CREDENTIALING PROFESSIONAL
Credential:
Phone: 407-447-7120