Healthcare Provider Details

I. General information

NPI: 1285687632
Provider Name (Legal Business Name): BORIS E CORONADO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N MAITLAND AVE STE 101
MAITLAND FL
32751-4499
US

IV. Provider business mailing address

800 N MAITLAND AVE STE 101
MAITLAND FL
32751-4499
US

V. Phone/Fax

Practice location:
  • Phone: 407-660-7150
  • Fax: 407-660-7108
Mailing address:
  • Phone: 407-660-7150
  • Fax: 407-660-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0072110
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME72110
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: