Provider Demographics
NPI:1992748776
Name:WINTER HAVEN CARDIOVASCULAR ASSOCIATES PL
Entity type:Organization
Organization Name:WINTER HAVEN CARDIOVASCULAR ASSOCIATES PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TREVA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WIDDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-787-9838
Mailing Address - Street 1:700 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7314
Mailing Address - Country:US
Mailing Address - Phone:352-787-9838
Mailing Address - Fax:352-787-8705
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:2 MAIN ENDO HALL #4
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:863-294-8400
Practice Address - Fax:863-294-8536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL98928OtherBCBS OF FLORIDA
FL273688800Medicaid
FL98928OtherBCBS OF FLORIDA
FLDE2902Medicare PIN