Provider Demographics
NPI:1063494631
Name:MYDLARZ, DARIUSZ GRZEGORZ (MD)
Entity Type:Individual
Prefix:DR
First Name:DARIUSZ
Middle Name:GRZEGORZ
Last Name:MYDLARZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6416 OLD WINTER GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-1348
Mailing Address - Country:US
Mailing Address - Phone:407-751-7288
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:6336 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-7812
Practice Address - Country:US
Practice Address - Phone:407-219-5200
Practice Address - Fax:321-281-8700
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235066208D00000X
FLME139388208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME139388OtherMEDICAL LICENSE