Healthcare Provider Details

I. General information

NPI: 1982634796
Provider Name (Legal Business Name): CENTERWELL SENIOR PRIMARY CARE (FL) INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14075 TOWN LOOP BLVD
ORLANDO FL
32837-6132
US

IV. Provider business mailing address

4700 MILLENIA BLVD STE 650
ORLANDO FL
32839-6013
US

V. Phone/Fax

Practice location:
  • Phone: 407-438-5858
  • Fax: 407-438-7172
Mailing address:
  • Phone: 407-447-7120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGIE MARTINEZ
Title or Position: SENIOR CREDENTIALING PROFESSIONAL
Credential:
Phone: 407-447-7120