Healthcare Provider Details

I. General information

NPI: 1750224580
Provider Name (Legal Business Name): PHANTHIRA PUGDEETHOSAPOL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 VETERANS WAY
ORLANDO FL
32827-7401
US

IV. Provider business mailing address

10500 SW 108TH AVE APT B107
MIAMI FL
33176-8601
US

V. Phone/Fax

Practice location:
  • Phone: 407-631-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberUO11286
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: