Provider Demographics
NPI:1255193124
Name:RESTORA MEDICAL
Entity type:Organization
Organization Name:RESTORA MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:JENNIFER
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-662-1649
Mailing Address - Street 1:1515 PARK CENTER DR UNIT J
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5794
Mailing Address - Country:US
Mailing Address - Phone:321-662-1649
Mailing Address - Fax:
Practice Address - Street 1:1515 PARK CENTER DR UNIT J
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5794
Practice Address - Country:US
Practice Address - Phone:321-662-1649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1790170454OtherPECOS