Healthcare Provider Details

I. General information

NPI: 1346567484
Provider Name (Legal Business Name): LAUREL OAKS FAMILY PRACTICE OF CENTRAL FLORIDA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 MAGUIRE RD
OCOEE FL
34761-4797
US

IV. Provider business mailing address

2711 MAGUIRE RD
OCOEE FL
34761-4797
US

V. Phone/Fax

Practice location:
  • Phone: 407-877-1990
  • Fax: 407-877-1995
Mailing address:
  • Phone: 407-877-1990
  • Fax: 407-877-1995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS7986
License Number StateFL

VIII. Authorized Official

Name: DR. JAMES BRADLEY WILSON JR.
Title or Position: PRESIDENT
Credential: D.O.
Phone: 407-877-1990