Provider Demographics
NPI:1326775230
Name:OSORIO, WDSVING A (MD)
Entity Type:Individual
Prefix:DR
First Name:WDSVING
Middle Name:A
Last Name:OSORIO
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 1:1005 N LK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4723
Mailing Address - Country:US
Mailing Address - Phone:863-583-4053
Mailing Address - Fax:
Practice Address - Street 1:1005 N LK PARK AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4723
Practice Address - Country:US
Practice Address - Phone:863-583-4053
Practice Address - Fax:863-248-8288
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2023-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22898207Q00000X
FL1507208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty