Healthcare Provider Details

I. General information

NPI: 1700118239
Provider Name (Legal Business Name): LUCILLE BELNICK MD PA CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2010
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5474 LAKE HOWELL RD
WINTER PARK FL
32792-1034
US

IV. Provider business mailing address

5474 LAKE HOWELL ROAD
WINTER PARK FL
32792
US

V. Phone/Fax

Practice location:
  • Phone: 407-679-3400
  • Fax: 407-679-3412
Mailing address:
  • Phone: 407-679-3400
  • Fax: 407-679-3412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME65336
License Number StateFL

VIII. Authorized Official

Name: MRS. LUCILLE B BELNICK
Title or Position: OWNER
Credential: M.D.
Phone: 407-679-3400