=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568716645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIAN NEXT DOOR, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2012
-----------------------------------------------------
Last Update Date | 06/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1834 N ALAFAYA TRL STE C
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32826-4743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-870-0199
-----------------------------------------------------
Fax | 941-870-0203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1834 N ALAFAYA TRL STE C
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32826-4743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-870-0199
-----------------------------------------------------
Fax | 941-870-0203
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL / SHAREHOLDER
-----------------------------------------------------
Name | MR. GABRIEL NURIEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 941-870-0199
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | OS7691
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------