1942237730 NPI number — DR. MARIBELLE DE LA TORRE REYES PH.D

Table of content: DR. MARIBELLE DE LA TORRE REYES PH.D (NPI 1942237730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942237730 NPI number — DR. MARIBELLE DE LA TORRE REYES PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA TORRE REYES
Provider First Name:
MARIBELLE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DE LA TORRE REYES
Provider Other First Name:
MARIBELLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1942237730
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3108 SUNWATCH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESLEY CHAPEL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33544-7720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-525-1113
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 HAYS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32301-2699
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-525-1113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2006

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: 103TC0700X , with the licence number:  PY10380 , 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: 102328200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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