Healthcare Provider Details

I. General information

NPI: 1962509562
Provider Name (Legal Business Name): MARIA DE LOS ANGELES VALDIVIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2006
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 SW 1ST ST 320
MIAMI FL
33135-2321
US

IV. Provider business mailing address

1393 SW 1ST ST 320
MIAMI FL
33135-2321
US

V. Phone/Fax

Practice location:
  • Phone: 305-644-0977
  • Fax: 305-644-0977
Mailing address:
  • Phone: 305-644-0977
  • Fax: 305-644-0977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME38920
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: