Healthcare Provider Details

I. General information

NPI: 1568323129
Provider Name (Legal Business Name): DEREJE YIDEG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2025
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 LAKE AMBERLEIGH DR
WINTER GARDEN FL
34787-5250
US

IV. Provider business mailing address

309 LAKE AMBERLEIGH DR
WINTER GARDEN FL
34787-5250
US

V. Phone/Fax

Practice location:
  • Phone: 813-522-9895
  • Fax: 813-522-9895
Mailing address:
  • Phone: 813-522-9895
  • Fax: 813-522-9895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: