Healthcare Provider Details

I. General information

NPI: 1033245287
Provider Name (Legal Business Name): RICHARD PANCHO GAJO MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2007
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 S SEMORAN BLVD STE 300
ORLANDO FL
32822-2500
US

IV. Provider business mailing address

10395 NARCOOSSEE RD E
ORLANDO FL
32832-6939
US

V. Phone/Fax

Practice location:
  • Phone: 407-281-0228
  • Fax: 407-281-0229
Mailing address:
  • Phone: 407-730-3244
  • Fax: 407-730-3246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT18613
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: