Provider Demographics
NPI:1194837476
Name:PRATLEY, RICHARD EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EDWIN
Last Name:PRATLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 N ORANGE AVE
Mailing Address - Street 2:SUITE 502
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5505
Mailing Address - Country:US
Mailing Address - Phone:407-303-2801
Mailing Address - Fax:407-303-2805
Practice Address - Street 1:2415 N ORANGE AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804
Practice Address - Country:US
Practice Address - Phone:407-303-2801
Practice Address - Fax:407-303-2805
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0010757207RG0300X
FLME110521207RG0300X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010563Medicaid
FL004133800Medicaid
NY02554814Medicaid
VN3409Medicare ID - Type Unspecified
FLFM368ZMedicare PIN
VT1010563Medicaid