Healthcare Provider Details

I. General information

NPI: 1801420955
Provider Name (Legal Business Name): ANTHONY J GUSTITUS JR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N ORANGE AVE STE 502
ORLANDO FL
32804-5503
US

IV. Provider business mailing address

735 MAIN LN APT 3112
ORLANDO FL
32801-3737
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2801
  • Fax: 407-303-2805
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11005863
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: