Healthcare Provider Details

I. General information

NPI: 1023646825
Provider Name (Legal Business Name): MARYBETH ARCEO BURRISS-WEST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARYBETH ARCEO BURRISS

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 W MILLER ST
ORLANDO FL
32806-2032
US

IV. Provider business mailing address

92 W MILLER ST
ORLANDO FL
32806-2032
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-5104
  • Fax: 321-841-6871
Mailing address:
  • Phone: 321-841-5104
  • Fax: 321-841-6871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME184380
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number261027
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number261027
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: