Healthcare Provider Details

I. General information

NPI: 1952378929
Provider Name (Legal Business Name): BRIAN WIBOON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5143 TILDENS GROVE BLVD
WINDERMERE FL
34786-5702
US

IV. Provider business mailing address

5143 TILDENS GROVE BLVD
WINDERMERE FL
34786-5702
US

V. Phone/Fax

Practice location:
  • Phone: 407-656-9908
  • Fax: 407-656-9908
Mailing address:
  • Phone: 407-656-9908
  • Fax: 407-656-9908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS0008848
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: