Provider Demographics
NPI:1033680848
Name:FOTOS, PRISCILLA JAIME
Entity type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:JAIME
Last Name:FOTOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 WEAVER DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7028
Mailing Address - Country:US
Mailing Address - Phone:407-319-4619
Mailing Address - Fax:
Practice Address - Street 1:1037 WEAVER DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-7028
Practice Address - Country:US
Practice Address - Phone:407-319-4619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT34218208100000X, 225100000X
CA299214225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPT34218OtherLICENSE