Basic Information
Provider Information
NPI: 1003144981
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WOJNOWICH
FirstName: TALI
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1845 VETERANS PARK DR
Address2: #260
City: NAPLES
State: FL
PostalCode: 341090493
CountryCode: US
TelephoneNumber: (239) 624-0570
FaxNumber: 2392547959
Practice Location
Address1: 1845 VETERANS PARK DR STE 260
Address2:  
City: NAPLES
State: FL
PostalCode: 341090494
CountryCode: US
TelephoneNumber: 2396240570
FaxNumber: 2392547959
Other Information
ProviderEnumerationDate: 12/03/2009
LastUpdateDate: 08/28/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
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AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000XME127600FLY Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
01767070005FL MEDICAID
IQ062Z01FLMEDICAREOTHER


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