Healthcare Provider Details

I. General information

NPI: 1629641113
Provider Name (Legal Business Name): JOMAR BERAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 N SEMORAN BLVD
WINTER PARK FL
32792-2840
US

IV. Provider business mailing address

3263 TIMUCUA CIR
ORLANDO FL
32837-7136
US

V. Phone/Fax

Practice location:
  • Phone: 407-679-1515
  • Fax:
Mailing address:
  • Phone: 321-948-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number31194
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: