Healthcare Provider Details

I. General information

NPI: 1750303699
Provider Name (Legal Business Name): IVAN JARED WORTMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7848 W IRLO BRONSON MEMORIAL HWY
KISSIMMEE FL
34747-1729
US

IV. Provider business mailing address

6129 LINNEAL BEACH DR
APOPKA FL
32703-7807
US

V. Phone/Fax

Practice location:
  • Phone: 407-397-7032
  • Fax: 407-397-7041
Mailing address:
  • Phone: 407-299-2055
  • Fax: 407-299-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME0063259
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: