Provider Demographics
NPI:1467459107
Name:WINDHAM, WAYNE (MD)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:WINDHAM
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 150505
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32715-0505
Mailing Address - Country:US
Mailing Address - Phone:407-767-0433
Mailing Address - Fax:407-767-0608
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-303-1944
Practice Address - Fax:407-303-1746
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME419372085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300118683OtherRR MEDICARE
FL068171700Medicaid
FL47540OtherBCBS OF FLORIDA
FL068171700Medicaid
FL47540RMedicare PIN
FL47540NMedicare PIN
FL47540OtherBCBS OF FLORIDA