Healthcare Provider Details

I. General information

NPI: 1316231608
Provider Name (Legal Business Name): GEORGE T BESONG MD OB/GYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 ENTERPRISE RD SUITE 200
ORANGE CITY FL
32763-8276
US

IV. Provider business mailing address

2728 ENTERPRISE RD SUITE 200
ORANGE CITY FL
32763-8276
US

V. Phone/Fax

Practice location:
  • Phone: 386-774-0109
  • Fax: 386-774-1203
Mailing address:
  • Phone: 386-774-0109
  • Fax: 386-774-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberME123086
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME123086
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberME92729
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. GEORGE TATAW BESONG
Title or Position: OWNER
Credential: M.D
Phone: 386-279-0060