Healthcare Provider Details

I. General information

NPI: 1982847133
Provider Name (Legal Business Name): EUNICE CORDOBA MDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12959 PALMS WEST DR SUITE 120
LOXAHATCHEE FL
33470-4937
US

IV. Provider business mailing address

12959 PALMS WEST DR SUITE 120
LOXAHATCHEE FL
33470-4937
US

V. Phone/Fax

Practice location:
  • Phone: 305-803-9887
  • Fax:
Mailing address:
  • Phone: 305-803-9887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberME 92149
License Number StateFL

VIII. Authorized Official

Name: MRS. EUNICE CORDOBA
Title or Position: MD
Credential: M.D.
Phone: 561-687-5837