Healthcare Provider Details

I. General information

NPI: 1578639209
Provider Name (Legal Business Name): LOUIS J RADNOTHY DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 S CENTRAL AVE
UMATILLA FL
32784-2325
US

IV. Provider business mailing address

PO BOX 2325
UMATILLA FL
32784-2325
US

V. Phone/Fax

Practice location:
  • Phone: 352-669-3175
  • Fax: 352-669-3640
Mailing address:
  • Phone: 352-669-3175
  • Fax: 352-669-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DHARTI BISHT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 352-669-3175