Provider Demographics
NPI:1033728076
Name:DE PUIGDORFILA, MIGUEL J
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:J
Last Name:DE PUIGDORFILA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-5302
Mailing Address - Country:US
Mailing Address - Phone:505-900-1476
Mailing Address - Fax:352-753-7141
Practice Address - Street 1:837 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-5302
Practice Address - Country:US
Practice Address - Phone:505-900-1476
Practice Address - Fax:352-753-7141
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDOM1263171100000X
FLAP4157171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP4157OtherMEDICAL LICENSE