Provider Demographics
NPI:1063499119
Name:URDANETA, JAVIER (MD)
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:URDANETA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:727-322-3439
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:5414 DEEP LAKE RD STE 1104
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-5243
Practice Address - Country:US
Practice Address - Phone:407-986-9850
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378071600Medicaid
FL378071600Medicaid
FL27391TMedicare PIN