MEDICARE: MOUNT DORA MEDICAL INSTITUTE INC 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	207R00000X	Internal Medicine Physician

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	:	1912691593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNT DORA MEDICAL INSTITUTE INC LLC

Provider Business Mailing Address
First Line	:	1898 N DONNELLY ST
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-2820
Country	:	US
Telephone Number	:	352-720-3149
Fax Number	:	352-800-4054

Provider Business Practice Location Address
First Line	:	1898 N DONNELLY ST
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-2820
Country	:	US
Telephone Number	:	352-720-3149
Fax Number	:	352-800-4054

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	CAITLYN PAIGE WHITEHEAD
Credential	:
Telephone Number	:	352-445-0778

Provider Enumeration Date	:	06/06/2023
Last Update Date	:	08/22/2023

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