Healthcare Provider Details

I. General information

NPI: 1326677980
Provider Name (Legal Business Name): EDWARD JACOB PRANGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 WATERMAN WAY
TAVARES FL
32778-5250
US

IV. Provider business mailing address

PO BOX 751069
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 352-742-0054
  • Fax: 352-742-4814
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME182595
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: