Healthcare Provider Details

I. General information

NPI: 1801603717
Provider Name (Legal Business Name): AGE REJUVENATION MEDICAL, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 N ORLANDO AVE STE 115
WINTER PARK FL
32789-3605
US

IV. Provider business mailing address

2409 N FALKENBURG RD
TAMPA FL
33619-0915
US

V. Phone/Fax

Practice location:
  • Phone: 407-565-5929
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: YAZMYNE MIRANDA
Title or Position: COO
Credential:
Phone: 954-682-3015