Healthcare Provider Details

I. General information

NPI: 1225662497
Provider Name (Legal Business Name): EFRAIN GOTAY CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 LUGANO CT
KISSIMMEE FL
34746-3434
US

IV. Provider business mailing address

14453 CHINESE ELM DR
ORLANDO FL
32828-4837
US

V. Phone/Fax

Practice location:
  • Phone: 321-442-2454
  • Fax: 407-386-3006
Mailing address:
  • Phone: 973-392-7676
  • Fax: 407-386-3006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: