Healthcare Provider Details

I. General information

NPI: 1508840604
Provider Name (Legal Business Name): MARY WILLSON YEILDING OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 09/17/2022
Certification Date: 09/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E NEW HAMPSHIRE ST
ORLANDO FL
32804-6403
US

IV. Provider business mailing address

2059 WOODLAWN DR
ORLANDO FL
32803-1652
US

V. Phone/Fax

Practice location:
  • Phone: 407-584-7207
  • Fax:
Mailing address:
  • Phone: 407-222-3451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3389
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: