Healthcare Provider Details

I. General information

NPI: 1780556985
Provider Name (Legal Business Name): DYUTI PEDDAPULI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W LAKE MARY BLVD STE 220
LAKE MARY FL
32746-3499
US

IV. Provider business mailing address

3300 W LAKE MARY BLVD STE 220
LAKE MARY FL
32746-3499
US

V. Phone/Fax

Practice location:
  • Phone: 407-321-7111
  • Fax: 407-321-7446
Mailing address:
  • Phone: 407-321-7111
  • Fax: 407-321-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: