1669744017 NPI number — RONNIE PEDROSA BARGAYO PT

Table of content: RONNIE PEDROSA BARGAYO PT (NPI 1669744017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669744017 NPI number — RONNIE PEDROSA BARGAYO PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARGAYO
Provider First Name:
RONNIE
Provider Middle Name:
PEDROSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1669744017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/22/2017
NPI Reactivation Date:
04/25/2018

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16244 S MILITARY TRL
Provider Second Line Business Mailing Address:
SUITE 750
Provider Business Mailing Address City Name:
DELRAY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33484-6534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-701-5073
Provider Business Mailing Address Fax Number:
561-450-6716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16244 S MILITARY TRL
Provider Second Line Business Practice Location Address:
SUITE 750
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33484-6534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-701-5073
Provider Business Practice Location Address Fax Number:
561-450-6716
Provider Enumeration Date:
02/01/2012

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: 225100000X , with the licence number:  032350 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3471014 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".