Healthcare Provider Details

I. General information

NPI: 1295968311
Provider Name (Legal Business Name): ADAM P PASTERNAK D.O., C.A.Q.S.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2009
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 S WILLIAMSON BLVD STE 700
PORT ORANGE FL
32128-8321
US

IV. Provider business mailing address

5535 S WILLIAMSON BLVD STE 700
PORT ORANGE FL
32128-8321
US

V. Phone/Fax

Practice location:
  • Phone: 386-231-6300
  • Fax: 386-322-6165
Mailing address:
  • Phone: 386-231-6300
  • Fax: 386-322-6165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2014024991
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS16317
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS16317
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: