Provider Demographics
NPI:1164056073
Name:URRUTIA, EDISON
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:
Last Name:URRUTIA
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 1:3003 CONNER LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7727
Mailing Address - Country:US
Mailing Address - Phone:321-846-3189
Mailing Address - Fax:
Practice Address - Street 1:222 BROADWAY UNIT 211
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5760
Practice Address - Country:US
Practice Address - Phone:407-329-3464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-29
Last Update Date:2020-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator