Healthcare Provider Details

I. General information

NPI: 1639599194
Provider Name (Legal Business Name): FREDELY PETIOTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N ORANGE AVE STE 800
ORLANDO FL
32801-2381
US

IV. Provider business mailing address

111 N ORANGE AVE STE 800
ORLANDO FL
32801-2381
US

V. Phone/Fax

Practice location:
  • Phone: 253-922-4027
  • Fax: 844-222-0800
Mailing address:
  • Phone: 313-427-7645
  • Fax: 844-222-0800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME161341
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: