Provider Demographics
NPI:1730646787
Name:MAGIC MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:MAGIC MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:786-518-1911
Mailing Address - Street 1:9421 S ORANGE BLOSSOM TRL STE 19
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32837-8320
Mailing Address - Country:US
Mailing Address - Phone:407-601-2527
Mailing Address - Fax:407-674-7640
Practice Address - Street 1:9421 S ORANGE BLOSSOM TRL STE 19
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-8320
Practice Address - Country:US
Practice Address - Phone:407-601-2527
Practice Address - Fax:407-674-7640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty