1255429882 NPI number — MR. VIRGILIO SIERRA MOTR/L

Table of content: MR. VIRGILIO SIERRA MOTR/L (NPI 1255429882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255429882 NPI number — MR. VIRGILIO SIERRA MOTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIERRA
Provider First Name:
VIRGILIO
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MOTR/L
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIERRA
Provider Other First Name:
VIRGIL
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MOTR/L
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1255429882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1526 WHITE HALL DR
Provider Second Line Business Mailing Address:
#406
Provider Business Mailing Address City Name:
DAVIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33324-6678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-382-2178
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3157 N UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE #103
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33024-2258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-442-9422
Provider Business Practice Location Address Fax Number:
954-442-9150
Provider Enumeration Date:
10/10/2006

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: 225XP0200X , with the licence number:  OT11800 , 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: 8903255 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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