1063767747 NPI number — MR. EDWIN MELENDEZ-CORTES B.A

Table of content: MR. EDWIN MELENDEZ-CORTES B.A (NPI 1063767747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063767747 NPI number — MR. EDWIN MELENDEZ-CORTES B.A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELENDEZ-CORTES
Provider First Name:
EDWIN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
B.A
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:
1063767747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2789 ORTIZ AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33905-7806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-275-3222
Provider Business Mailing Address Fax Number:
239-278-9058

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2789 ORTIZ AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-275-3222
Provider Business Practice Location Address Fax Number:
239-278-9058
Provider Enumeration Date:
07/18/2012

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M453200722560 . This is a "FLORIDA DRIVER LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".