Provider Demographics
NPI:1306048343
Name:GOOD SHEPHERD PRIMARY CARE, P.A.
Entity type:Organization
Organization Name:GOOD SHEPHERD PRIMARY CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIBEL
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-282-4142
Mailing Address - Street 1:1170 S SEMORAN BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-1458
Mailing Address - Country:US
Mailing Address - Phone:407-282-4142
Mailing Address - Fax:407-282-7475
Practice Address - Street 1:1170 S SEMORAN BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1458
Practice Address - Country:US
Practice Address - Phone:407-282-4142
Practice Address - Fax:407-282-7475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066465207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF40961Medicare UPIN