Healthcare Provider Details

I. General information

NPI: 1164827010
Provider Name (Legal Business Name): OB/GYN ULTRASOUND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 S SEMORAN BLVD SUITE A
ORLANDO FL
32822-4811
US

IV. Provider business mailing address

5800 S SEMORAN BLVD SUITE A
ORLANDO FL
32822-4811
US

V. Phone/Fax

Practice location:
  • Phone: 407-270-5925
  • Fax: 407-205-1494
Mailing address:
  • Phone: 407-270-5925
  • Fax: 407-205-1494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME98764
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number120313
License Number StateFL

VIII. Authorized Official

Name: LUIS FERNANCO TOBON
Title or Position: MEDICAL DIRECTOR
Credential: M.D., FACOG
Phone: 407-492-5931