1477886737 NPI number — MILA SEGUERRA-DOCTURA MD PA

Table of content: (NPI 1477886737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477886737 NPI number — MILA SEGUERRA-DOCTURA MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILA SEGUERRA-DOCTURA 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:
6
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:
1477886737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 SHAMROCK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VENICE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34293-1630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-493-3282
Provider Business Mailing Address Fax Number:
941-493-1672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 SHAMROCK BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34293-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-493-3282
Provider Business Practice Location Address Fax Number:
941-493-1672
Provider Enumeration Date:
09/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
SEGUERRA-DOCTORA MD PA
Authorized Official First Name:
MILA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
941-493-3282

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME0032680 , 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: 214206 . This is a "AMERIGROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 28840 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 58312 . This is a "BXBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 464714 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 0386901-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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