=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740733872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORGE E. GARAYUA, M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2016
-----------------------------------------------------
Last Update Date | 07/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4788 LAKE CALABAY DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837-5435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-251-6649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7758 WALLACE RD STE C&D
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-7219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-250-6002
-----------------------------------------------------
Fax | 407-203-3139
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PHYSICIAN
-----------------------------------------------------
Name | DR. JORGE ESTEBAN GARAYUA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 407-913-5842
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME97664
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------