Provider Demographics
NPI:1215390711
Name:OLAZABAL PUPO, YOEL (MD)
Entity Type:Individual
Prefix:
First Name:YOEL
Middle Name:
Last Name:OLAZABAL PUPO
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 1:7649 W COLONIAL DR STE 115
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-7423
Mailing Address - Country:US
Mailing Address - Phone:407-522-2080
Mailing Address - Fax:833-963-0115
Practice Address - Street 1:7649 W COLONIAL DR STE 115
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-7423
Practice Address - Country:US
Practice Address - Phone:407-522-2080
Practice Address - Fax:833-963-0115
Is Sole Proprietor?:No
Enumeration Date:2016-04-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA164723208D00000X
390200000X
CA164723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL95-2707101Medicaid
FLME158724OtherSTATE LICENSE
FL116234300Medicaid
FLFO8732821OtherDEA