Healthcare Provider Details

I. General information

NPI: 1528304987
Provider Name (Legal Business Name): MIRINDA ANN GILLESPIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 03/23/2022
Certification Date: 03/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 PENNSYLVANIA ST # MP303
ORLANDO FL
32806-2937
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 407-649-6876
  • Fax:
Mailing address:
  • Phone: 904-697-4127
  • Fax: 904-697-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA166008
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME132470
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number132470
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: