Healthcare Provider Details

I. General information

NPI: 1174580492
Provider Name (Legal Business Name): ELEFTHERIOS P MAMOUNAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE STE 389
ORLANDO FL
32804-4623
US

IV. Provider business mailing address

2501 N ORANGE AVE STE 389
ORLANDO FL
32804-4623
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-5214
  • Fax:
Mailing address:
  • Phone: 407-303-5214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35072102M
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME114413
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME114413
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: