Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207V00000X | Obstetrician & Gynecologist | ME63371 | FL |
Y | 207VG0400X | Gynecologist | ME63371 | FL |
NPI | 1174528236 |
---|---|
Provider Name | Mr. Richard A. Real |
First Address | Kissimmee, FL 34744-1617 |
Second Address | Kissimmee, FL 34744-1617 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2005 |
Last Update Date | 01/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
376506700 | (05) | FL |
ME63371 | MEDICAL LICENSE (01) | FL |