Provider Demographics
NPI:1316416027
Name:VAJDA, DIMITRA
Entity Type:Individual
Prefix:MRS
First Name:DIMITRA
Middle Name:
Last Name:VAJDA
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:PO BOX 2419
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33883-2419
Mailing Address - Country:US
Mailing Address - Phone:813-703-1632
Mailing Address - Fax:
Practice Address - Street 1:304 3RD ST SW STE 20
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3409
Practice Address - Country:US
Practice Address - Phone:813-703-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL1229273224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist