Healthcare Provider Details

I. General information

NPI: 1326239872
Provider Name (Legal Business Name): KATERINA ANGELIQUE BACKUS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE UNIT 514
ORLANDO FL
32804-4603
US

IV. Provider business mailing address

2501 N ORANGE AVE UNIT 514
ORLANDO FL
32804-4603
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-5687
  • Fax: 407-303-0806
Mailing address:
  • Phone: 407-303-5687
  • Fax: 407-303-0806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME98967
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberME98967
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: