Provider Demographics
NPI:1790169423
Name:RUTTY ESPINOZA, ANGELO
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:
Last Name:RUTTY ESPINOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7620 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-8223
Mailing Address - Country:US
Mailing Address - Phone:412-587-2022
Mailing Address - Fax:
Practice Address - Street 1:871 VINELAND RD STE B
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-3938
Practice Address - Country:US
Practice Address - Phone:407-978-0227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN946208D00000X, 208D00000X
PR019116261QE0002X, 261QH0100X, 261QP2300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care