Healthcare Provider Details

I. General information

NPI: 1295730737
Provider Name (Legal Business Name): TUNG T WYNN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 918025
ORLANDO FL
32891-8025
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-7999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberME87818
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: