Healthcare Provider Details

I. General information

NPI: 1831418037
Provider Name (Legal Business Name): ROBERT DE LA TORRE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ZEAGLER DR
PALATKA FL
32177-3810
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 386-328-5711
  • Fax: 386-325-8178
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME78337
License Number StateFL

VIII. Authorized Official

Name: ROBERT DE LA TORRE
Title or Position: OWNER
Credential: MD
Phone: 904-824-4990