1245478965 NPI number — ROBERTO A LLANTADA MD PA

Table of content: (NPI 1245478965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245478965 NPI number — ROBERTO A LLANTADA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROBERTO A LLANTADA MD 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:
1245478965
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3831 PALM AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIALEAH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33012-4445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-557-0092
Provider Business Mailing Address Fax Number:
305-557-0450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3831 PALM AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33012-4445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-557-0092
Provider Business Practice Location Address Fax Number:
305-557-0450
Provider Enumeration Date:
02/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LLANTADA
Authorized Official First Name:
ROBERTO
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING DIRECTOR
Authorized Official Telephone Number:
305-557-0092

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  ME28478 , 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: 016491100 . 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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