Provider Demographics
NPI:1043690423
Name:LOSADA LEON, VANIOLKY (MD)
Entity Type:Individual
Prefix:MISS
First Name:VANIOLKY
Middle Name:
Last Name:LOSADA LEON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-1290
Mailing Address - Fax:239-343-4008
Practice Address - Street 1:13782 PLANTATION RD STE 201
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4462
Practice Address - Country:US
Practice Address - Phone:239-343-1290
Practice Address - Fax:239-343-4008
Is Sole Proprietor?:No
Enumeration Date:2015-06-01
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1486642084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110747800Medicaid