Provider Demographics
NPI:1740207547
Name:IDSTEN, WILFRED GRAY (MD)
Entity Type:Individual
Prefix:
First Name:WILFRED
Middle Name:GRAY
Last Name:IDSTEN
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 550643
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33655-0643
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-870-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46450207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30847OtherBLUE CROSS OF FLORIDA
FL30847OtherBLUE CROSS OF FLORIDA
FL30847WMedicare PIN