1396871307 NPI number — ROBERTO E PUENTE DPM PLLC

Table of content: (NPI 1396871307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396871307 NPI number — ROBERTO E PUENTE DPM PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERTO E PUENTE DPM PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HARBOR FOOT & LEG SPECIALISTS
Provider Other Organization Name Type Code:
3
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:
1396871307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21300 GERTRUDE AVE STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT CHARLOTTE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33952-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-883-4820
Provider Business Mailing Address Fax Number:
941-883-6086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21300 GERTRUDE AVE STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33952-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-883-4820
Provider Business Practice Location Address Fax Number:
941-883-6086
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PUENTE
Authorized Official First Name:
ROBERTO
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
941-883-4820

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  PO 2821 , 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: 65669 . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DE8265 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 340145600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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