Healthcare Provider Details

I. General information

NPI: 1972592087
Provider Name (Legal Business Name): TERESITA ALICEA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 DYER BLVD
KISSIMMEE FL
34741-7839
US

IV. Provider business mailing address

3070 DYER BLVD
KISSIMMEE FL
34741-7839
US

V. Phone/Fax

Practice location:
  • Phone: 407-932-7930
  • Fax: 407-932-7935
Mailing address:
  • Phone: 407-932-7930
  • Fax: 407-932-7935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME67925
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: