Provider Demographics
NPI:1689398349
Name:INGRAM, DEWAYNE OCTAVIAN
Entity Type:Individual
Prefix:MR
First Name:DEWAYNE
Middle Name:OCTAVIAN
Last Name:INGRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2739 WILLOWGATE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-4185
Mailing Address - Country:US
Mailing Address - Phone:321-280-0107
Mailing Address - Fax:
Practice Address - Street 1:2739 WILLOWGATE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-4185
Practice Address - Country:US
Practice Address - Phone:321-280-0107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver