Healthcare Provider Details

I. General information

NPI: 1881125714
Provider Name (Legal Business Name): WANDER HURTADO MARTINEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 ALOMA AVE STE 104
WINTER PARK FL
32792-9366
US

IV. Provider business mailing address

4270 ALOMA AVE STE 104
WINTER PARK FL
32792-9366
US

V. Phone/Fax

Practice location:
  • Phone: 321-788-2777
  • Fax: 321-788-2781
Mailing address:
  • Phone: 321-788-2777
  • Fax: 321-788-2781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME164661
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54197
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: