1457097412 NPI number — VANESSA MARIE CORDOVA OD

Table of content: VANESSA MARIE CORDOVA OD (NPI 1457097412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457097412 NPI number — VANESSA MARIE CORDOVA OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORDOVA
Provider First Name:
VANESSA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
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:
1457097412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2282
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANOVANAS
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00729-2282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-256-6060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR 3 KM 19.9 EAST MEDICAL PROFESSIONAL CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANOVANAS
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-256-6060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2022

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: 152W00000X , with the licence number:  757 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 757 . This is a "LICENSE OD" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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