Provider Demographics
NPI:1558366195
Name:BUMGARNER, MARILIZ BORBON (MD)
Entity Type:Individual
Prefix:DR
First Name:MARILIZ
Middle Name:BORBON
Last Name:BUMGARNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 CURRY FORD RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-8744
Mailing Address - Country:US
Mailing Address - Phone:239-600-9389
Mailing Address - Fax:407-286-4739
Practice Address - Street 1:5150 CURRY FORD RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-8744
Practice Address - Country:US
Practice Address - Phone:407-286-3653
Practice Address - Fax:407-286-4739
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL91688208000000X
FLME91688208000000X
FLME-91688208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1528161Medicaid
FL52180OtherBCBSH
FL7723670OtherAETNA
FLQMP000005411144Medicaid
FL271218100Medicaid