1154581205 NPI number — ANNE MARIE MENJIVAR O.D.

Table of content: ANNE MARIE MENJIVAR O.D. (NPI 1154581205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154581205 NPI number — ANNE MARIE MENJIVAR O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENJIVAR
Provider First Name:
ANNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.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:
1154581205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3130 SW 32ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34474-4445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-622-5183
Provider Business Mailing Address Fax Number:
352-622-2720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 SE MAGNOLIA EXT
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34471-4463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-622-5183
Provider Business Practice Location Address Fax Number:
352-622-2720
Provider Enumeration Date:
06/12/2008

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: 152WL0500X , with the licence number:  OPC 4393 , 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: 001244700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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