Provider Demographics
NPI:1356906358
Name:FLORIDA INSTITUTE OF DERMATOLOGY LLC
Entity type:Organization
Organization Name:FLORIDA INSTITUTE OF DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WAUDO
Authorized Official - Last Name:WANGIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-246-3254
Mailing Address - Street 1:10747 EMERALD CHASE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-5876
Mailing Address - Country:US
Mailing Address - Phone:352-246-3254
Mailing Address - Fax:
Practice Address - Street 1:1991 DANIELS RD
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787
Practice Address - Country:US
Practice Address - Phone:407-395-3770
Practice Address - Fax:407-395-3779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-06
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty