1891783221 NPI number — LEYBERTH MARIO ROSENDO MD

Table of content: LEYBERTH MARIO ROSENDO MD (NPI 1891783221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891783221 NPI number — LEYBERTH MARIO ROSENDO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSENDO
Provider First Name:
LEYBERTH
Provider Middle Name:
MARIO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1891783221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
661 E ALTAMONTE DR STE 324
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTAMONTE SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32701-5103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-303-3031
Provider Business Mailing Address Fax Number:
407-303-3047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
661 E ALTAMONTE DR STE 324
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTAMONTE SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32701-5103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-303-3031
Provider Business Practice Location Address Fax Number:
407-303-3047
Provider Enumeration Date:
10/10/2005

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:  ME72708 , 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: 252128800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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