Healthcare Provider Details

I. General information

NPI: 1609243989
Provider Name (Legal Business Name): FAMILY TREE MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2015
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 CYPRESS GLEN CIR
KISSIMMEE FL
34741-7560
US

IV. Provider business mailing address

1150 CYPRESS GLEN CIR
KISSIMMEE FL
34741-7560
US

V. Phone/Fax

Practice location:
  • Phone: 407-483-3200
  • Fax: 407-483-3220
Mailing address:
  • Phone: 407-483-3200
  • Fax: 407-483-3220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. VICTOR MANUEL PANTOJA JR.
Title or Position: CEO
Credential: CEO
Phone: 407-483-3200