Provider Demographics
NPI:1609243989
Name:FAMILY TREE MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:FAMILY TREE MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:PANTOJA
Authorized Official - Suffix:JR
Authorized Official - Credentials:CEO
Authorized Official - Phone:407-483-3200
Mailing Address - Street 1:1150 CYPRESS GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7560
Mailing Address - Country:US
Mailing Address - Phone:407-483-3200
Mailing Address - Fax:407-483-3220
Practice Address - Street 1:1150 CYPRESS GLEN CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7560
Practice Address - Country:US
Practice Address - Phone:407-483-3200
Practice Address - Fax:407-483-3220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017306100Medicaid
FLIV484AOtherMEDICARE