Healthcare Provider Details

I. General information

NPI: 1376233346
Provider Name (Legal Business Name): ORLANDO PRIMARY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11616 LAKE UNDERHILL RD STE 205
ORLANDO FL
32825-4466
US

IV. Provider business mailing address

11616 LAKE UNDERHILL RD STE 215
ORLANDO FL
32825-4465
US

V. Phone/Fax

Practice location:
  • Phone: 407-601-5308
  • Fax: 407-482-8698
Mailing address:
  • Phone: 407-601-5308
  • Fax: 407-482-8698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VINEEL SOMPALLI
Title or Position: MANAGER
Credential: MD
Phone: 407-482-7788