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General NPI Number Information
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NPI Number | 1902210172
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Entity Type | Organization
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Legal Business Name | GAYNOR MEDICAL PRACTICE
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Dates
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Enumeration Date | 06/16/2014
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Last Update Date | 06/16/2014
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Provider Practice Location Address
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Address Line | 10 W GROVE AVE SUITE 108
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City | LAKE WALES
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State | FL
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Zip | 33853-4516
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Country | US
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Telephone | 407-325-5227
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Fax |
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Provider Business Mailing Address
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Address Line | 9483 WICKHAM WAY
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City | ORLANDO
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State | FL
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Zip | 32836-5521
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Country | US
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Telephone | 407-325-5227
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ROBERT GAYNOR
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Credential | D.O.
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Telephone | 407-325-5227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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