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General NPI Number Information
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NPI Number | 1518382647
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Entity Type | Organization
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Legal Business Name | ST CLOUD GASTROENTEROLOGY PLLC
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Dates
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Enumeration Date | 02/26/2014
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Last Update Date | 09/04/2018
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Provider Practice Location Address
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Address Line | 2801 13TH STREET
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City | SAINT CLOUD
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State | FL
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Zip | 34769
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Country | US
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Telephone | 407-892-8925
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Fax | 407-892-8926
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Provider Business Mailing Address
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Address Line | 2801 13TH STREET
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City | SAINT CLOUD
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State | FL
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Zip | 34769-4134
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Country | US
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Telephone | 407-892-8925
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Fax | 407-892-8926
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Authorized Official
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Title or Position | OWNER
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Name | DR. RAFAEL FLEITES
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Credential | M.D.
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Telephone | 407-892-8925
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | ME35796
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License Number State | FL
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