Provider Demographics
NPI:1124609599
Name:CUDDEBACK, MARIS
Entity type:Individual
Prefix:
First Name:MARIS
Middle Name:
Last Name:CUDDEBACK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-905-8827
Mailing Address - Fax:321-221-9454
Practice Address - Street 1:7900 FOREST CITY RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-3002
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-654-4079
Is Sole Proprietor?:No
Enumeration Date:2021-04-17
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME169302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program