Healthcare Provider Details

I. General information

NPI: 1548463003
Provider Name (Legal Business Name): MOIN H KOLA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N ORANGE AVE STE 200
ORLANDO FL
32804-5505
US

IV. Provider business mailing address

100 N DEAN RD STE 101
ORLANDO FL
32825-3710
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-1812
  • Fax: 407-303-1815
Mailing address:
  • Phone: 407-384-7388
  • Fax: 407-384-7391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME101271
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: