Healthcare Provider Details

I. General information

NPI: 1316416027
Provider Name (Legal Business Name): MRS. DIMITRA VAJDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 3RD ST SW STE 20
WINTER HAVEN FL
33880-3409
US

IV. Provider business mailing address

PO BOX 2419
WINTER HAVEN FL
33883-2419
US

V. Phone/Fax

Practice location:
  • Phone: 813-703-1632
  • Fax:
Mailing address:
  • Phone: 813-703-1632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCL1229273
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: