MEDICARE: PHYSICIAN NEXT DOOR, 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	OS7691	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HM571A	OTHER	FL	MEDICARE PTAN

General Provider Information

NPI Number	:	1568716645
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN NEXT DOOR, LLC

Provider Business Mailing Address
First Line	:	1834 N ALAFAYA TRL
Second Line	:	STE C
City	:	ORLANDO
State	:	FL
Zip	:	32826-4743
Country	:	US
Telephone Number	:	941-870-0199
Fax Number	:	941-870-0203

Provider Business Practice Location Address
First Line	:	1834 N ALAFAYA TRL
Second Line	:	STE C
City	:	ORLANDO
State	:	FL
Zip	:	32826-4743
Country	:	US
Telephone Number	:	941-870-0199
Fax Number	:	941-870-0203

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL / SHAREHOLDER
Name	:	MR. GABRIEL NURIEL
Credential	:
Telephone Number	:	941-870-0199

Provider Enumeration Date	:	10/29/2012
Last Update Date	:	06/24/2015

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Directions to “PHYSICIAN NEXT DOOR, LLC ” Practice Location

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