=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669445862
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PROSPERO ANTONIO CORTORREAL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2006
-----------------------------------------------------
Last Update Date | 09/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4759 US HWY 19 NEW PORT RICHEY PRIMARY CARE CENTER
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-4945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-841-8772
-----------------------------------------------------
Fax | 727-842-4727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4759 US HWY 19 NEW PORT RICHEY PRIMARY CARE CENTER
-----------------------------------------------------
City | NEW PORT RICHEY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34652-4945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-841-8772
-----------------------------------------------------
Fax | 727-842-4727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME73702
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------