MEDICARE: MR. SERGIO E VALDIVIA PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT10727	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	001872584	OTHER		HIGHMARK BCBS
2	Y053N	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1225030166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SERGIO E VALDIVIA PT

Provider Business Mailing Address
First Line	:	PO BOX 1551
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34284-1551
Country	:	US
Telephone Number	:	941-468-1660
Fax Number	:	941-484-6024

Provider Business Practice Location Address
First Line	:	12355 SW COUNTY ROAD 769
Second Line	:	SUITE B
City	:	LAKE SUZY
State	:	FL
Zip	:	34269-5923
Country	:	US
Telephone Number	:	941-468-1660
Fax Number	:	941-484-6024

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	06/23/2008

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