1164907747 NPI number — WIDALYS GARCIA-MARTINEZ

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164907747 NPI number — WIDALYS GARCIA-MARTINEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARCIA-MARTINEZ
Provider First Name:
WIDALYS
Provider Middle Name:
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:
1164907747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7667 N WICKHAM RD
Provider Second Line Business Mailing Address:
APT # 1205
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-617-2969
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 MABBETTE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KISSIMMEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34741-5161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-201-8079
Provider Business Practice Location Address Fax Number:
407-343-9180
Provider Enumeration Date:
09/28/2018

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: 235Z00000X , with the licence number:  8545 , 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: 8545 . This is a "DEPARTMENT OF HEALTH- DIVISION OF MEDICAL QUALITY ASSURANCE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 101132300 . 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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