Healthcare Provider Details

I. General information

NPI: 1124054333
Provider Name (Legal Business Name): BRONWYN RUDDY STALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 182
ORLANDO FL
32804-4675
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2030
  • Fax: 407-303-2040
Mailing address:
  • Phone: 407-303-2030
  • Fax: 407-303-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number0101239937
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME136490
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: