Healthcare Provider Details

I. General information

NPI: 1194837476
Provider Name (Legal Business Name): RICHARD EDWIN PRATLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N ORANGE AVE SUITE 502
ORLANDO FL
32804
US

IV. Provider business mailing address

2415 N ORANGE AVE SUITE 502
ORLANDO FL
32804-5505
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2801
  • Fax: 407-303-2805
Mailing address:
  • Phone: 407-303-2801
  • Fax: 407-303-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number042-0010757
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME110521
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME110521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: