Healthcare Provider Details

I. General information

NPI: 1316933799
Provider Name (Legal Business Name): CENTRAL FLORIDA PEDIATRIC INTENSVIE CARE SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 N THORNTON AVE
ORLANDO FL
32803-4003
US

IV. Provider business mailing address

844 N THORNTON AVE
ORLANDO FL
32803-4003
US

V. Phone/Fax

Practice location:
  • Phone: 407-894-8768
  • Fax:
Mailing address:
  • Phone: 407-894-8768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME58278
License Number StateFL

VIII. Authorized Official

Name: DR. AYODEJI V OTEGBEYE
Title or Position: PHYSICIAN
Credential: MD
Phone: 407-894-8768