Healthcare Provider Details

I. General information

NPI: 1609676360
Provider Name (Legal Business Name): LIVINGSTON MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2025
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E ROBINSON ST STE 1120
ORLANDO FL
32801-1962
US

IV. Provider business mailing address

200 E ROBINSON ST STE 1120
ORLANDO FL
32801-1962
US

V. Phone/Fax

Practice location:
  • Phone: 407-329-2571
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID MANTOR
Title or Position: MANAGER
Credential:
Phone: 407-329-2571