1437336690 NPI number — CORAL J VILLANUEVA DPM PA

Table of content: (NPI 1437336690)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437336690 NPI number — CORAL J VILLANUEVA DPM PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORAL J VILLANUEVA 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:
1437336690
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6540 NW 114TH AVE
Provider Second Line Business Mailing Address:
APT 1403
Provider Business Mailing Address City Name:
DORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33178-4587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-859-3509
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1090 KANE CONCOURSE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
BAY HARBOR ISLANDS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33154-2130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-893-9366
Provider Business Practice Location Address Fax Number:
305-893-4408
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VILLANUEVA
Authorized Official First Name:
CORAL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
786-859-3509

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  PO3285 , 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)





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