Provider Demographics
NPI:1760476956
Name:HALL, WYNTON L JR (MD,FACS)
Entity Type:Individual
Prefix:
First Name:WYNTON
Middle Name:L
Last Name:HALL
Suffix:JR
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:302 BRYAN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5337
Mailing Address - Country:US
Mailing Address - Phone:813-681-7512
Mailing Address - Fax:813-684-8974
Practice Address - Street 1:302 BRYAN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5337
Practice Address - Country:US
Practice Address - Phone:813-681-7512
Practice Address - Fax:813-684-8974
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME35424208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30632ZMedicare PIN