Healthcare Provider Details

I. General information

NPI: 1073380358
Provider Name (Legal Business Name): ZACHARY BETHEL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2023
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W CRYSTAL LAKE ST
ORLANDO FL
32806-4475
US

IV. Provider business mailing address

25 W CRYSTAL LAKE ST
ORLANDO FL
32806-4475
US

V. Phone/Fax

Practice location:
  • Phone: 407-254-2500
  • Fax:
Mailing address:
  • Phone: 407-254-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number33074
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: