Healthcare Provider Details

I. General information

NPI: 1124609599
Provider Name (Legal Business Name): MARIS CUDDEBACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2021
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 FOREST CITY RD
ORLANDO FL
32810-3002
US

IV. Provider business mailing address

110 S WOODLAND ST
WINTER GARDEN FL
34787-3546
US

V. Phone/Fax

Practice location:
  • Phone: 407-905-8827
  • Fax: 407-654-4079
Mailing address:
  • Phone: 407-905-8827
  • Fax: 321-221-9454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME169302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: