Healthcare Provider Details

I. General information

NPI: 1396925574
Provider Name (Legal Business Name): KISSIMMEE PRIMARY CARE ANTI-AGING WELLNESS AND WEIGHT LOSS CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 02/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 N JOHN YOUNG PKWY
KISSIMMEE FL
34741-3219
US

IV. Provider business mailing address

1520 N JOHN YOUNG PKWY
KISSIMMEE FL
34741-3219
US

V. Phone/Fax

Practice location:
  • Phone: 407-518-7700
  • Fax: 407-518-7100
Mailing address:
  • Phone: 407-518-7700
  • Fax: 407-518-7100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MOHAMED H GAJRAJ
Title or Position: PRESIDENT
Credential: MD
Phone: 407-518-7700