MEDICARE: OMNI FAMILY MEDICINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician	ME0037307	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063785095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI FAMILY MEDICINE, LLC

Provider Business Mailing Address
First Line	:	8030 SAINT JAMES WAY
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-9134
Country	:	US
Telephone Number	:	407-908-0064
Fax Number	:	352-383-9319

Provider Business Practice Location Address
First Line	:	8030 SAINT JAMES WAY
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-9134
Country	:	US
Telephone Number	:	407-908-0064
Fax Number	:	352-383-9319

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JERRY M ALSTOTT
Credential	:	M.D.
Telephone Number	:	407-908-0064

Provider Enumeration Date	:	02/22/2012
Last Update Date	:	05/10/2016

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Directions to “OMNI FAMILY MEDICINE, LLC ” Practice Location

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