Basic Information
| Provider Information | |||||||||
| NPI: | 1659753945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATANABE BALLARTA | ||||||||
| FirstName: | DORA | ||||||||
| MiddleName: | EIKO MITSUE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 4079058998 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 CAGAN VIEW RD | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347146405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 4079058998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2015 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 31682-R | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | ME147690 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.