Healthcare Provider Details

I. General information

NPI: 1558366195
Provider Name (Legal Business Name): MARILIZ BORBON BUMGARNER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 CURRY FORD RD
ORLANDO FL
32812-8744
US

IV. Provider business mailing address

5150 CURRY FORD RD
ORLANDO FL
32812-8744
US

V. Phone/Fax

Practice location:
  • Phone: 407-286-3653
  • Fax: 407-286-4739
Mailing address:
  • Phone: 239-600-9389
  • Fax: 407-286-4739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number91688
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME-91688
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME91688
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: