Healthcare Provider Details

I. General information

NPI: 1689073819
Provider Name (Legal Business Name): GARRY B ANTOINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5844 N ORANGE BLOSSOM TRL
ORLANDO FL
32810-1025
US

IV. Provider business mailing address

PO BOX 951306
LAKE MARY FL
32795-1306
US

V. Phone/Fax

Practice location:
  • Phone: 407-602-1100
  • Fax: 407-219-4221
Mailing address:
  • Phone: 407-602-1100
  • Fax: 407-219-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number18854
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN675
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: