Basic Information
Provider Information | |||||||||
NPI: | 1992748776 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WINTER HAVEN CARDIOVASCULAR ASSOCIATES PL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 700 DOCTORS CT | ||||||||
Address2: |   | ||||||||
City: | LEESBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 347487314 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527879838 | ||||||||
FaxNumber: | 3527878705 | ||||||||
Practice Location | |||||||||
Address1: | 200 AVENUE F NE | ||||||||
Address2: | 2 MAIN ENDO HALL #4 | ||||||||
City: | WINTER HAVEN | ||||||||
State: | FL | ||||||||
PostalCode: | 338814131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8632948400 | ||||||||
FaxNumber: | 8632948536 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2006 | ||||||||
LastUpdateDate: | 06/05/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WIDDIS | ||||||||
AuthorizedOfficialFirstName: | TREVA | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 3527879838 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/05/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   |
ID Information
ID | Type | State | Issuer | Description | 98928 | 01 | FL | BCBS OF FLORIDA | OTHER | 273688800 | 05 | FL |   | MEDICAID |