Provider Demographics
NPI:1932133279
Name:MILDRED TAVERAS TREVETT MD PA
Entity Type:Organization
Organization Name:MILDRED TAVERAS TREVETT MD PA
Other - Org Name:INTERNAL MEDICINE GRP OF CENTRAL FL DBA LAKE NONA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TREVETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-802-1102
Mailing Address - Street 1:10437 MOSS PARK RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32832
Mailing Address - Country:US
Mailing Address - Phone:407-802-1100
Mailing Address - Fax:407-802-1111
Practice Address - Street 1:10437 MOSS PARK RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832
Practice Address - Country:US
Practice Address - Phone:407-802-1100
Practice Address - Fax:407-802-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
FLME73656208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL41986YMedicare UPIN
FLK2040Medicare ID - Type UnspecifiedGRP NUMBER