1760676548 NPI number — MA. LIZA ANN FLORES FAMADOR MD

Table of content: MA. LIZA ANN FLORES FAMADOR MD (NPI 1760676548)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760676548 NPI number — MA. LIZA ANN FLORES FAMADOR MD

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
FAMADOR

Provider First Name:
MA. LIZA ANN

Provider Middle Name:
FLORES

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:
MD

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:
1760676548

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
07/27/2009

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
311 DORIC AVE

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
CRANSTON

Provider Business Mailing Address State Name:
RI

Provider Business Mailing Address Postal Code:
02910-2903

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
401-467-9610

Provider Business Mailing Address Fax Number:
401-467-9030

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
191 MACARTHUR BLVD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
COVENTRY

Provider Business Practice Location Address State Name:
RI

Provider Business Practice Location Address Postal Code:
02816-7244

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
401-828-7688

Provider Business Practice Location Address Fax Number:
401-828-2914

Provider Enumeration Date:
09/05/2007

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: 207Q00000X , with the licence number: MT187985 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 207Q00000X , with the licence number: MD13039 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .