Provider Demographics
NPI:1679503486
Name:BURGOS, FAUSTO RONALD (MD)
Entity Type:Individual
Prefix:
First Name:FAUSTO
Middle Name:RONALD
Last Name:BURGOS
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 1:4034 GREENLEAF DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-9150
Mailing Address - Country:US
Mailing Address - Phone:407-242-0293
Mailing Address - Fax:
Practice Address - Street 1:12301 LAKE UNDERHILL RD STE 215
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4511
Practice Address - Country:US
Practice Address - Phone:321-235-0692
Practice Address - Fax:321-235-0694
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062672207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593650014OtherTAX ID