Provider Demographics
NPI:1912691593
Name:MOUNT DORA MEDICAL INSTITUTE INC LLC
Entity Type:Organization
Organization Name:MOUNT DORA MEDICAL INSTITUTE INC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CAITLYN
Authorized Official - Middle Name:PAIGE
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-445-0778
Mailing Address - Street 1:1898 N DONNELLY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-2820
Mailing Address - Country:US
Mailing Address - Phone:352-720-3149
Mailing Address - Fax:352-800-4054
Practice Address - Street 1:1898 N DONNELLY ST
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-2820
Practice Address - Country:US
Practice Address - Phone:352-720-3149
Practice Address - Fax:352-800-4054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty