Provider Demographics
NPI:1073639969
Name:MOUNT DORA FAMILY PRACTICE PA
Entity type:Organization
Organization Name:MOUNT DORA FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-383-7743
Mailing Address - Street 1:18540 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6725
Mailing Address - Country:US
Mailing Address - Phone:352-383-7743
Mailing Address - Fax:352-383-9226
Practice Address - Street 1:18540 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6725
Practice Address - Country:US
Practice Address - Phone:352-383-7743
Practice Address - Fax:352-383-9226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDA2650OtherRR MEDICARE
FL274649200Medicaid
FLG19132Medicare UPIN
FL27928VMedicare ID - Type Unspecified