1578690483 NPI number — MARIBELLE VERDIALES MD

Table of content: MARIBELLE VERDIALES MD (NPI 1578690483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578690483 NPI number — MARIBELLE VERDIALES MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERDIALES
Provider First Name:
MARIBELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VERDIALES-GOMEZ
Provider Other First Name:
MARIBELLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1578690483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 W SPRING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30655-1751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-266-0935
Provider Business Mailing Address Fax Number:
770-266-0931

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 W SPRING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30655-1751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-266-0935
Provider Business Practice Location Address Fax Number:
770-266-0931
Provider Enumeration Date:
02/27/2007

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: 207V00000X , with the licence number:  061871 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 300137757A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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