Basic Information
| Provider Information | |||||||||
| NPI: | 1699205310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLUMBIE SARDINAS | ||||||||
| FirstName: | WILMER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 S ORANGE AVE STE 940 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328013234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076589687 | ||||||||
| FaxNumber: | 4072864515 | ||||||||
| Practice Location | |||||||||
| Address1: | 3162 CONWAY RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328127331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076270056 | ||||||||
| FaxNumber: | 4072370355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 19666 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN964 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | FC6907705 | 01 | FL | DEA | OTHER | 07469000 | 01 | PR | ECFMG | OTHER | 1699205310 | 01 | FL | NPI | OTHER |