Healthcare Provider Details

I. General information

NPI: 1528198546
Provider Name (Legal Business Name): CAROLYN DEWALDEN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10131 W COLONIAL DR SUITE 4
OCOEE FL
34761-4221
US

IV. Provider business mailing address

605 STRIHAL LOOP
OAKLAND FL
34787-8958
US

V. Phone/Fax

Practice location:
  • Phone: 407-298-4910
  • Fax: 407-296-2638
Mailing address:
  • Phone: 407-877-0984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9102038
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: