Provider Demographics
NPI:1154341956
Name:WILFONG, ADAM (MD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WILFONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919392
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-9392
Mailing Address - Country:US
Mailing Address - Phone:352-544-6050
Mailing Address - Fax:
Practice Address - Street 1:17240 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8921
Practice Address - Country:US
Practice Address - Phone:305-544-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME65476207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251882100Medicaid
FL26579YMedicare PIN
FL26579XMedicare PIN
FLF97002Medicare UPIN
FL251882100Medicaid