Healthcare Provider Details

I. General information

NPI: 1033387865
Provider Name (Legal Business Name): HEATHROW INTERNAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 W LAKE MARY BLVD SUITE 100
LAKE MARY FL
32746-3315
US

IV. Provider business mailing address

4106 W LAKE MARY BLVD SUITE 100
LAKE MARY FL
32746-3315
US

V. Phone/Fax

Practice location:
  • Phone: 407-333-2273
  • Fax: 407-333-3939
Mailing address:
  • Phone: 407-333-2273
  • Fax: 407-333-3939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. TEDRICK JOHNSON
Title or Position: GROUP VP OPERATIONS
Credential:
Phone: 407-333-2273