Provider Demographics
NPI:1558464669
Name:MAITLAND FAMILY PRACTICE
Entity Type:Organization
Organization Name:MAITLAND FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WALDHEIM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:407-628-4312
Mailing Address - Street 1:402 LAKE HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5907
Mailing Address - Country:US
Mailing Address - Phone:407-628-4312
Mailing Address - Fax:407-628-1845
Practice Address - Street 1:402 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5907
Practice Address - Country:US
Practice Address - Phone:407-628-4312
Practice Address - Fax:407-628-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265582900Medicaid
FL265582900Medicaid