Provider Demographics
NPI:1073622247
Name:CENTRAL FLORIDA FAMILY MEDICAL GROUP
Entity Type:Organization
Organization Name:CENTRAL FLORIDA FAMILY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.F.O
Authorized Official - Prefix:
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-281-9105
Mailing Address - Street 1:1170 S SEMORAN BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-1458
Mailing Address - Country:US
Mailing Address - Phone:407-281-9105
Mailing Address - Fax:
Practice Address - Street 1:1170 S SEMORAN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1458
Practice Address - Country:US
Practice Address - Phone:407-281-9105
Practice Address - Fax:407-281-9305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty