Provider Demographics
NPI:1497059737
Name:MY ENDOCRINOLOGIST PA
Entity Type:Organization
Organization Name:MY ENDOCRINOLOGIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIBEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTOYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-409-7103
Mailing Address - Street 1:213 S DILLARD ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3522
Mailing Address - Country:US
Mailing Address - Phone:407-409-8067
Mailing Address - Fax:407-409-8068
Practice Address - Street 1:213 S DILLARD ST
Practice Address - Street 2:SUITE 240
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3522
Practice Address - Country:US
Practice Address - Phone:407-409-8067
Practice Address - Fax:407-409-8068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-30
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84429207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEP586AMedicare PIN