Provider Demographics
NPI:1194821611
Name:NAZARIO-VIDAL, GLORIMAR (MD)
Entity Type:Individual
Prefix:MRS
First Name:GLORIMAR
Middle Name:
Last Name:NAZARIO-VIDAL
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 29866
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00929-0866
Mailing Address - Country:US
Mailing Address - Phone:787-530-0510
Mailing Address - Fax:787-998-6733
Practice Address - Street 1:2804 W MARC KNIGHTON CT
Practice Address - Street 2:SUITE A
Practice Address - City:LECANTO
Practice Address - State:FL
Practice Address - Zip Code:34461-6300
Practice Address - Country:US
Practice Address - Phone:352-746-8000
Practice Address - Fax:352-746-8001
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13579207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7000005932OtherETON NUMBER MEDICARE
PRH67640Medicare UPIN
PR0020746Medicare ID - Type Unspecified