Provider Demographics
NPI:1336356492
Name:THE FAMILY PHYSICIAN OF BVL
Entity Type:Organization
Organization Name:THE FAMILY PHYSICIAN OF BVL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:DR
Authorized Official - First Name:FAUSTO
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-348-9111
Mailing Address - Street 1:3071 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-1501
Mailing Address - Country:US
Mailing Address - Phone:407-348-9111
Mailing Address - Fax:407-348-9112
Practice Address - Street 1:3071 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1501
Practice Address - Country:US
Practice Address - Phone:407-348-9111
Practice Address - Fax:407-348-9112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62672173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF46753Medicare UPIN