Provider Demographics
NPI:1003313487
Name:VYDRA, DEBORAH IVANE (DO)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:IVANE
Last Name:VYDRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:IVANE
Other - Last Name:WIRAWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DEBORAH IVANE WIRAWA
Mailing Address - Street 1:8990 R G SKINNER PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-4020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8990 R G SKINNER PKWY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-4020
Practice Address - Country:US
Practice Address - Phone:904-519-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17827208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program