Healthcare Provider Details

I. General information

NPI: 1710170568
Provider Name (Legal Business Name): GARY VISSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2007
Last Update Date: 04/05/2022
Certification Date: 04/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 MAGUIRE RD STE 200
OCOEE FL
34761-4751
US

IV. Provider business mailing address

2940 MAGUIRE RD STE 200
OCOEE FL
34761-4751
US

V. Phone/Fax

Practice location:
  • Phone: 407-581-9065
  • Fax: 321-348-5827
Mailing address:
  • Phone: 407-581-9065
  • Fax: 321-348-5827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME105459
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME105459
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: