1962775130 NPI number — DR. MARIAM EMILIA TOVAR DOM

Table of content: DR. MARIAM EMILIA TOVAR DOM (NPI 1962775130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962775130 NPI number — DR. MARIAM EMILIA TOVAR DOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TOVAR
Provider First Name:
MARIAM
Provider Middle Name:
EMILIA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DOM
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:
1962775130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5804 LAKE UNDEHILL RD. STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-867-6610
Provider Business Mailing Address Fax Number:
407-203-6898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11557 AMIDSHIP LN UNIT 7307
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDERMERE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34786-5535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-867-6610
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2012

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: 171100000X , with the licence number:  AP3091 , 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)