1003902214 NPI number — DR. IVAN PUENTE M.D.

Table of content: DR. IVAN PUENTE M.D. (NPI 1003902214)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003902214 NPI number — DR. IVAN PUENTE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PUENTE
Provider First Name:
IVAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003902214
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 E COMMERCIAL BLVD STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-4202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-491-0900
Provider Business Mailing Address Fax Number:
954-491-1306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 E COMMERCIAL BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-4202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-491-0900
Provider Business Practice Location Address Fax Number:
954-491-1306
Provider Enumeration Date:
10/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  ME55971 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: ME55971 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: ME55971 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)