Provider Demographics
NPI:1316496003
Name:MEDSTATION ORLANDO PRIMARY CARE LLC
Entity type:Organization
Organization Name:MEDSTATION ORLANDO PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AMBR
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:COLOMBINO
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-394-5535
Mailing Address - Street 1:1601 PARK CENTER DR
Mailing Address - Street 2:SUITE # 9
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-5700
Mailing Address - Country:US
Mailing Address - Phone:321-219-9301
Mailing Address - Fax:954-582-6715
Practice Address - Street 1:1601 PARK CENTER DR
Practice Address - Street 2:SUITE # 9
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5700
Practice Address - Country:US
Practice Address - Phone:321-219-9301
Practice Address - Fax:954-582-6715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049457207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1316936461OtherNPI
FL006455900Medicaid
FL02718CMedicare UPIN