Healthcare Provider Details

I. General information

NPI: 1275523227
Provider Name (Legal Business Name): OLIVER KENNETH BAYOUTH JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3431 S ORANGE AVE STE B
ORLANDO FL
32806-8508
US

IV. Provider business mailing address

3431 S ORANGE AVE STE B
ORLANDO FL
32806-8508
US

V. Phone/Fax

Practice location:
  • Phone: 407-425-4422
  • Fax: 407-425-4294
Mailing address:
  • Phone: 407-425-4422
  • Fax: 407-425-4294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME0045179
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberME0045179
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberME0045179
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME0045179
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: