Healthcare Provider Details

I. General information

NPI: 1619125622
Provider Name (Legal Business Name): AVI ELIZABETH DOMNITZ-GEBET DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 NEPTUNE RD
SAINT CLOUD FL
34769-6741
US

IV. Provider business mailing address

4107 NEPTUNE RD
SAINT CLOUD FL
34769-6741
US

V. Phone/Fax

Practice location:
  • Phone: 321-805-4398
  • Fax:
Mailing address:
  • Phone: 321-805-4398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberOS15654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: