Healthcare Provider Details

I. General information

NPI: 1295419844
Provider Name (Legal Business Name): JACOB RYAN MARTY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 FOWLER GROVE BLVD
WINTER GARDEN FL
34787-5050
US

IV. Provider business mailing address

2501 N ORANGE AVE SUITE 235, BOX 38
ORLANDO FL
32804-4659
US

V. Phone/Fax

Practice location:
  • Phone: 407-614-0500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS23751
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: