Provider Demographics
NPI:1942201561
Name:COMENENCIA, EDSEL J (MD)
Entity Type:Individual
Prefix:MR
First Name:EDSEL
Middle Name:J
Last Name:COMENENCIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDSEL
Other - Middle Name:J
Other - Last Name:COMENENCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M,D
Mailing Address - Street 1:7148 CURRY FORD RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-5803
Mailing Address - Country:US
Mailing Address - Phone:407-482-2221
Mailing Address - Fax:407-482-2284
Practice Address - Street 1:7148 CURRY FORD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-5803
Practice Address - Country:US
Practice Address - Phone:407-482-2221
Practice Address - Fax:407-482-2284
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78656207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258070500Medicaid
FLE69542Medicare UPIN
FL258070500Medicaid