Provider Demographics
NPI:1083806269
Name:WOODLAND LAKES FAMILY PRACTICE PA
Entity Type:Organization
Organization Name:WOODLAND LAKES FAMILY PRACTICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:321-235-0970
Mailing Address - Street 1:13000 AVALON LAKE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-6434
Mailing Address - Country:US
Mailing Address - Phone:321-235-0970
Mailing Address - Fax:321-235-0971
Practice Address - Street 1:13000 AVALON LAKE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-6434
Practice Address - Country:US
Practice Address - Phone:321-235-0970
Practice Address - Fax:321-235-0971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S5964208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL57150VMedicare PIN
FLAF195Medicare PIN
F60908Medicare UPIN