Provider Demographics
NPI:1821171406
Name:BRUSCATO, ELIZA G (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELIZA
Middle Name:G
Last Name:BRUSCATO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2028
Mailing Address - Country:US
Mailing Address - Phone:321-841-5281
Mailing Address - Fax:407-425-5947
Practice Address - Street 1:83 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2028
Practice Address - Country:US
Practice Address - Phone:321-841-5281
Practice Address - Fax:407-425-5947
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049162207V00000X
FLME117001207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009392700Medicaid
FLME117001OtherMEDICAL LICENSE
GA000884903HMedicaid
GA000884903GMedicaid
FL009392700Medicaid
FLHN567ZMedicare PIN