Provider Demographics
NPI:1093977167
Name:AVALON PARK FAMILY MEDICINE
Entity Type:Organization
Organization Name:AVALON PARK FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-380-7966
Mailing Address - Street 1:13000 AVALON LAKE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6448
Mailing Address - Country:US
Mailing Address - Phone:321-235-0967
Mailing Address - Fax:321-235-0968
Practice Address - Street 1:13000 AVALON LAKE DR
Practice Address - Street 2:STE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-6448
Practice Address - Country:US
Practice Address - Phone:407-380-7966
Practice Address - Fax:407-380-7988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57150VMedicare UPIN