Healthcare Provider Details

I. General information

NPI: 1487823274
Provider Name (Legal Business Name): WINTER HAVEN CARDIOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 1ST ST N
WINTER HAVEN FL
33881-4113
US

IV. Provider business mailing address

320 1ST ST N
WINTER HAVEN FL
33881-4113
US

V. Phone/Fax

Practice location:
  • Phone: 863-294-5505
  • Fax: 863-299-5660
Mailing address:
  • Phone: 863-294-5505
  • Fax: 863-299-5660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME36699
License Number StateFL

VIII. Authorized Official

Name: DR. GARY ROBERT JOHNSON
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 863-508-0202