Provider Demographics
NPI:1790725117
Name:CENTRAL FL REG OBSTETRICS AND GYNECOLOGY, LLC
Entity Type:Organization
Organization Name:CENTRAL FL REG OBSTETRICS AND GYNECOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-523-2117
Mailing Address - Street 1:1000 EXECUTIVE DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-8140
Mailing Address - Country:US
Mailing Address - Phone:407-365-2929
Mailing Address - Fax:
Practice Address - Street 1:1000 EXECUTIVE DR
Practice Address - Street 2:SUITE 3
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-8140
Practice Address - Country:US
Practice Address - Phone:407-365-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74908OtherBCBS OF FL
FL74908Medicare ID - Type Unspecified