Healthcare Provider Details

I. General information

NPI: 1053375782
Provider Name (Legal Business Name): ALYSIA CRUTCHFIELD OGBURIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7751 KINGSPOINTE PKWY STE 114
ORLANDO FL
32819
US

IV. Provider business mailing address

7751 KINGSPOINTE PKWY STE 114
ORLANDO FL
32819-6502
US

V. Phone/Fax

Practice location:
  • Phone: 407-581-9672
  • Fax:
Mailing address:
  • Phone: 407-581-9672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME103937
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: