Healthcare Provider Details

I. General information

NPI: 1467998252
Provider Name (Legal Business Name): PATH MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10967 LAKE UNDERHILL RD STE 120
ORLANDO FL
32825-4454
US

IV. Provider business mailing address

2304 W OAKLAND PARK BLVD
OAKLAND PARK FL
33311-1422
US

V. Phone/Fax

Practice location:
  • Phone: 407-367-3040
  • Fax: 407-367-3043
Mailing address:
  • Phone: 754-218-2164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NEIL BONNARDEL
Title or Position: DIRECTOR OF MEDICAL SERVICES
Credential: MD
Phone: 754-218-2164