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General NPI Number Information
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NPI Number | 1528278363
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Entity Type | Organization
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Legal Business Name | WINTER HAVEN DERMATOLOGY PA
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 05/14/2008
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Provider Practice Location Address
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Address Line | 560 AVENUE K SE
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City | WINTER HAVEN
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State | FL
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Zip | 33880-4203
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Country | US
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Telephone | 863-299-3376
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Fax |
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Provider Business Mailing Address
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Address Line | 560 AVENUE K SE
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City | WINTER HAVEN
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State | FL
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Zip | 33880-4203
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Country | US
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Telephone | 863-299-3376
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEPAN OLIVA
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Credential | MD
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Telephone | 863-299-3376
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | ME75639
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License Number State | FL
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