Provider Demographics
NPI:1952378929
Name:WIBOON, BRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:WIBOON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5143 TILDENS GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5702
Mailing Address - Country:US
Mailing Address - Phone:407-656-9908
Mailing Address - Fax:407-656-9908
Practice Address - Street 1:5143 TILDENS GROVE BLVD
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-5702
Practice Address - Country:US
Practice Address - Phone:407-656-9908
Practice Address - Fax:407-656-9908
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0008848207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71049OtherBCBS
FL267324000Medicaid
FL71049OtherBCBS
FL71049ZMedicare ID - Type UnspecifiedMEDICARE