Provider Demographics
NPI:1659753945
Name:WATANABE BALLARTA, DORA EIKO MITSUE (MD)
Entity Type:Individual
Prefix:
First Name:DORA
Middle Name:EIKO MITSUE
Last Name:WATANABE BALLARTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:407-905-8998
Practice Address - Street 1:509 CAGAN VIEW RD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34714-6405
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-905-8998
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
31682-R390200000X
FLME147690207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program