Healthcare Provider Details

I. General information

NPI: 1376172015
Provider Name (Legal Business Name): WIDDLER DESHOMMES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2020
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 N HIGHWAY 19A
MOUNT DORA FL
32757-2039
US

IV. Provider business mailing address

550 ROUZER ST
APOPKA FL
32712-3650
US

V. Phone/Fax

Practice location:
  • Phone: 352-290-8718
  • Fax:
Mailing address:
  • Phone: 407-575-0943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number023661
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000229-P.A
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8363
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTPPA363
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1610
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: