Healthcare Provider Details

I. General information

NPI: 1417260183
Provider Name (Legal Business Name): MDOPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2010
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12981 S ORANGE BLOSSOM TRL
ORLANDO FL
32837-6592
US

IV. Provider business mailing address

12981 S ORANGE BLOSSOM TRL
ORLANDO FL
32837-6592
US

V. Phone/Fax

Practice location:
  • Phone: 407-816-5958
  • Fax:
Mailing address:
  • Phone: 407-816-5958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MR. JUAN ALBERTO GONZALEZ
Title or Position: CEO
Credential:
Phone: 407-816-5958