1194821611 NPI number — MRS. GLORIMAR NAZARIO-VIDAL M.D.

Table of content: MRS. GLORIMAR NAZARIO-VIDAL M.D. (NPI 1194821611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194821611 NPI number — MRS. GLORIMAR NAZARIO-VIDAL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NAZARIO-VIDAL
Provider First Name:
GLORIMAR
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1194821611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 29866
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00929-0866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-530-0510
Provider Business Mailing Address Fax Number:
787-998-6733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2804 W MARC KNIGHTON CT
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LECANTO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34461-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-746-8000
Provider Business Practice Location Address Fax Number:
352-746-8001
Provider Enumeration Date:
09/15/2006

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: 207R00000X , with the licence number:  13579 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7000005932 . This is a "ETON NUMBER MEDICARE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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