Healthcare Provider Details

I. General information

NPI: 1093330110
Provider Name (Legal Business Name): PRESTON H PALM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W UNDERWOOD ST FL 3
ORLANDO FL
32806-1122
US

IV. Provider business mailing address

77 W UNDERWOOD ST FL 3
ORLANDO FL
32806-1122
US

V. Phone/Fax

Practice location:
  • Phone: 407-649-6884
  • Fax: 407-245-7059
Mailing address:
  • Phone: 407-649-6884
  • Fax: 407-245-7059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: