Provider Demographics
NPI:1326239872
Name:BACKUS, KATERINA ANGELIQUE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATERINA
Middle Name:ANGELIQUE
Last Name:BACKUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2501 N ORANGE AVE
Mailing Address - Street 2:UNIT 514
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4603
Mailing Address - Country:US
Mailing Address - Phone:407-303-5687
Mailing Address - Fax:407-303-0806
Practice Address - Street 1:2501 N ORANGE AVE
Practice Address - Street 2:UNIT 514
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4603
Practice Address - Country:US
Practice Address - Phone:407-303-5687
Practice Address - Fax:407-303-0806
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98967208000000X, 2080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279148000Medicaid
AE693ZMedicare PIN
FL279148000Medicaid