Healthcare Provider Details

I. General information

NPI: 1679101091
Provider Name (Legal Business Name): TAISHA DESTIN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9400 TURKEY LAKE RD # MP452
ORLANDO FL
32819-8001
US

IV. Provider business mailing address

9400 TURKEY LAKE RD # MP452
ORLANDO FL
32819-8001
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-5500
  • Fax: 321-843-5550
Mailing address:
  • Phone: 321-843-5500
  • Fax: 321-843-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS19984
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: