1700954641 NPI number — MARIA I BOTERO-CARPENTER

Table of content: MARIA I BOTERO-CARPENTER (NPI 1700954641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700954641 NPI number — MARIA I BOTERO-CARPENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOTERO-CARPENTER
Provider First Name:
MARIA
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1700954641
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 FIELDSTREAM BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32825-7204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-482-8162
Provider Business Mailing Address Fax Number:
407-482-8162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4401 E COLONIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32803-5200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-898-5060
Provider Business Practice Location Address Fax Number:
407-898-5185
Provider Enumeration Date:
11/30/2006

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: 225X00000X , with the licence number:  OT6347 , 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)

  • Identifier: 830020800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".