Provider Demographics
NPI:1487823274
Name:WINTER HAVEN CARDIOLOGY PA
Entity Type:Organization
Organization Name:WINTER HAVEN CARDIOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-508-0202
Mailing Address - Street 1:320 1ST ST N
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4113
Mailing Address - Country:US
Mailing Address - Phone:863-294-5505
Mailing Address - Fax:863-299-5660
Practice Address - Street 1:320 1ST ST N
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4113
Practice Address - Country:US
Practice Address - Phone:863-294-5505
Practice Address - Fax:863-299-5660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36699174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77181AMedicare PIN
FLB74152Medicare UPIN