Healthcare Provider Details

I. General information

NPI: 1275518169
Provider Name (Legal Business Name): CECILIA R VENTURA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 WYOMING AVE
SCRANTON PA
18509-3023
US

IV. Provider business mailing address

PO BOX 31 959 WYOMING AVE.
SCRANTON PA
18501-0031
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-3517
  • Fax: 570-344-6839
Mailing address:
  • Phone: 570-344-3517
  • Fax: 570-344-6839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD020503E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0006601460002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: