Provider Demographics
NPI:1912573684
Name:FLORIDA INSTITUTE OF DERMATOLOGY LLC
Entity Type:Organization
Organization Name:FLORIDA INSTITUTE OF DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAUDO
Authorized Official - Last Name:WANGIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-395-3770
Mailing Address - Street 1:201 N PARK AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-4147
Mailing Address - Country:US
Mailing Address - Phone:407-395-3770
Mailing Address - Fax:407-395-3779
Practice Address - Street 1:201 N PARK AVE STE 204
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-4147
Practice Address - Country:US
Practice Address - Phone:407-395-3770
Practice Address - Fax:407-395-3779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103439400Medicaid