1053583856 NPI number — AMBERLY C PARADOA DPM PA

Table of content: (NPI 1053583856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053583856 NPI number — AMBERLY C PARADOA DPM PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMBERLY C PARADOA DPM PA
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:
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:
1053583856
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3735 11TH CIR
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
VERO BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32960-4844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-299-7009
Provider Business Mailing Address Fax Number:
772-562-7138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3735 11TH CIR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-4844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-299-7009
Provider Business Practice Location Address Fax Number:
772-562-7138
Provider Enumeration Date:
04/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PARADOA
Authorized Official First Name:
AMBERLY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
772-299-7009

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO3105 , 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: PO3105 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 340483800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6141470001 . This is a "MEDICARE DME" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 014653700 . 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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