Healthcare Provider Details

I. General information

NPI: 1780681247
Provider Name (Legal Business Name): PETER HENRY OOSTWOUDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4930 E LAKE MARY BLVD
SANFORD FL
32771-5003
US

IV. Provider business mailing address

4930 E LAKE MARY BLVD
SANFORD FL
32771-5003
US

V. Phone/Fax

Practice location:
  • Phone: 407-322-8645
  • Fax: 407-322-8725
Mailing address:
  • Phone: 407-322-8645
  • Fax: 407-322-8725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME54678
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: