Provider Demographics
NPI:1043546922
Name:SERENITY OF CENTRAL FLORIDA P.A.
Entity Type:Organization
Organization Name:SERENITY OF CENTRAL FLORIDA P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YASIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOUDRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-577-8197
Mailing Address - Street 1:PO BOX 1840
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32158-1840
Mailing Address - Country:US
Mailing Address - Phone:352-577-8197
Mailing Address - Fax:352-577-8741
Practice Address - Street 1:1114 W DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6312
Practice Address - Country:US
Practice Address - Phone:352-577-8197
Practice Address - Fax:352-577-8741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 96757103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDF476AMedicare UPIN