Healthcare Provider Details

I. General information

NPI: 1710926548
Provider Name (Legal Business Name): KENDALL K PETERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N ORANGE AVE STE 815
ORLANDO FL
32801-5203
US

IV. Provider business mailing address

2501 N ORANGE AVE SUITE 442
ORLANDO FL
32804-4603
US

V. Phone/Fax

Practice location:
  • Phone: 407-898-1436
  • Fax: 407-898-6330
Mailing address:
  • Phone: 407-898-1436
  • Fax: 407-898-6330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME100894
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number056206
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: