Healthcare Provider Details

I. General information

NPI: 1043694532
Provider Name (Legal Business Name): CORAL CANDELARIO-VELAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2015
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W GORE ST STE 600
ORLANDO FL
32806-1051
US

IV. Provider business mailing address

100 W GORE ST STE 600
ORLANDO FL
32806-1051
US

V. Phone/Fax

Practice location:
  • Phone: 321-842-4067
  • Fax: 321-843-6521
Mailing address:
  • Phone: 321-842-4067
  • Fax: 321-843-6521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number150122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: