Healthcare Provider Details

I. General information

NPI: 1902718463
Provider Name (Legal Business Name): THEODORE EUSTACHE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W COLONIAL DR STE 101
ORLANDO FL
32804-6863
US

IV. Provider business mailing address

12602 DOUGLAS FIR CT
CLERMONT FL
34711-6562
US

V. Phone/Fax

Practice location:
  • Phone: 305-878-6895
  • Fax:
Mailing address:
  • Phone: 305-878-6895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: