Provider Demographics
NPI:1245327246
Name:DUMORNAY, WILSON (MD)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:DUMORNAY
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 1:4101 S. HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-2857
Mailing Address - Country:US
Mailing Address - Phone:954-368-3348
Mailing Address - Fax:954-900-4720
Practice Address - Street 1:4101 S. HOSPITAL DRIVE
Practice Address - Street 2:SUITE 14
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2857
Practice Address - Country:US
Practice Address - Phone:954-368-3348
Practice Address - Fax:954-900-4720
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68723207Y00000X, 261QA1903X
FLME96799207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68723OtherGEORGIA MEDICAL LICENSE
FLME 96799OtherFLORIDA MEDICAL LICENSE
FLME 96799OtherFLORIDA MEDICAL LICENSE