Provider Demographics
NPI:1558074286
Name:DORELUS, WADVENS (D4G9H6Y6)
Entity type:Individual
Prefix:
First Name:WADVENS
Middle Name:
Last Name:DORELUS
Suffix:
Gender:M
Credentials:D4G9H6Y6
Other - Prefix:
Other - First Name:WADVENS
Other - Middle Name:
Other - Last Name:DORELUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MEDICAL ASSISTANT
Mailing Address - Street 1:421 W 30TH ST
Mailing Address - Street 2:MOBILIZE
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404
Mailing Address - Country:US
Mailing Address - Phone:561-568-6646
Mailing Address - Fax:
Practice Address - Street 1:421 W 30TH ST
Practice Address - Street 2:MOBILIZE
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404
Practice Address - Country:US
Practice Address - Phone:561-568-6646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD4G9H6Y6172A00000X, 174400000X, 207PH0002X, 372600000X, 374U00000X, 376K00000X, 405300000X, 156F00000X
D4G9H6Y63747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
No172A00000XOther Service ProvidersDriver
No174400000XOther Service ProvidersSpecialist
No207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD4G9H6Y6OtherMEDICAL ASSISTANT