1730789256 NPI number — FANNY MARITZA MUNIZ OD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730789256 NPI number — FANNY MARITZA MUNIZ OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUNIZ
Provider First Name:
FANNY
Provider Middle Name:
MARITZA
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:
GUTT
Provider Other First Name:
FANNY
Provider Other Middle Name:
MARITZA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730789256
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13217 CORTEZ BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKSVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34613-6807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-597-1209
Provider Business Mailing Address Fax Number:
877-210-5491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13217 CORTEZ BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKSVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34613-6807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-597-1209
Provider Business Practice Location Address Fax Number:
877-210-5491
Provider Enumeration Date:
10/26/2020

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:  OPC5879 , 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: 119657000 . 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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