Healthcare Provider Details

I. General information

NPI: 1578194379
Provider Name (Legal Business Name): LAKE NONA EMERGENCY PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6700 LAKE NONA BLVD
ORLANDO FL
32827-7729
US

IV. Provider business mailing address

5380 TECH DATA DR STE 101
CLEARWATER FL
33760-3122
US

V. Phone/Fax

Practice location:
  • Phone: 689-216-8000
  • Fax:
Mailing address:
  • Phone: 973-251-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132