Provider Demographics
NPI:1780681247
Name:OOSTWOUDER, PETER HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:HENRY
Last Name:OOSTWOUDER
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 1:4930 E LAKE MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-5003
Mailing Address - Country:US
Mailing Address - Phone:407-322-8645
Mailing Address - Fax:407-322-8725
Practice Address - Street 1:4930 E LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-5003
Practice Address - Country:US
Practice Address - Phone:407-322-8645
Practice Address - Fax:407-322-8725
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME54678207Q00000X
FLME 0054678207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL061660500Medicaid
FL01112201OtherAMERIGROUP
FL061660500Medicaid
FL24921OtherWELLCARE
FL061660500Medicaid
08198YMedicare Oscar/Certification