Healthcare Provider Details

I. General information

NPI: 1245627710
Provider Name (Legal Business Name): DANA MARIE OLDHAM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WATERMAN WAY
TAVARES FL
32778-5266
US

IV. Provider business mailing address

PO BOX 21991
BELFAST ME
04915-4116
US

V. Phone/Fax

Practice location:
  • Phone: 352-385-3032
  • Fax: 352-742-3581
Mailing address:
  • Phone: 386-231-3249
  • Fax: 386-672-9904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS15341
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: