Provider Demographics
NPI: | 1467459107 |
---|---|
Name: | WINDHAM, WAYNE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | WAYNE |
Middle Name: | |
Last Name: | WINDHAM |
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: | PO BOX 150505 |
Mailing Address - Street 2: | |
Mailing Address - City: | ALTAMONTE SPRINGS |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 32715-0505 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 407-767-0433 |
Mailing Address - Fax: | 407-767-0608 |
Practice Address - Street 1: | 601 E ROLLINS ST |
Practice Address - Street 2: | |
Practice Address - City: | ORLANDO |
Practice Address - State: | FL |
Practice Address - Zip Code: | 32803-1248 |
Practice Address - Country: | US |
Practice Address - Phone: | 407-303-1944 |
Practice Address - Fax: | 407-303-1746 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-07-07 |
Last Update Date: | 2014-02-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME41937 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 300118683 | Other | RR MEDICARE |
FL | 068171700 | Medicaid | |
FL | 47540 | Other | BCBS OF FLORIDA |
FL | 068171700 | Medicaid | |
FL | 47540R | Medicare PIN | |
FL | 47540N | Medicare PIN | |
FL | 47540 | Other | BCBS OF FLORIDA |