Healthcare Provider Details

I. General information

NPI: 1629017652
Provider Name (Legal Business Name): MOREY J. MENACKER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7649 W COLONIAL DR STE 115
ORLANDO FL
32818-7423
US

IV. Provider business mailing address

PO BOX 616788
ORLANDO FL
32861-6788
US

V. Phone/Fax

Practice location:
  • Phone: 407-552-2080
  • Fax: 339-630-1158
Mailing address:
  • Phone: 407-533-6835
  • Fax: 407-770-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMB43067
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS16624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: