=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255650081
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER PAYTHAL GANPAT M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2010
-----------------------------------------------------
Last Update Date | 04/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10129 CLEAR VISTA ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-7164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-663-6331
-----------------------------------------------------
Fax | 833-673-0418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 W COLONIAL DR STE 302
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32804-6863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-601-1370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME130503
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2014-01754
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 2014-01754
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME130503
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------