=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750414280
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IOANNIS JOHN GEORGIOU PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 CENTRAL FLORIDA BLVD UCF HEALTH CENTER
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32816-8005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-823-2646
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4250 ALAFAYA TRL STE 212 PMB 405
-----------------------------------------------------
City | OVIEDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32765-9424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-681-2022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA3212
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------