Provider Demographics
NPI:1225030166
Name:VALDIVIA, SERGIO E (PT)
Entity Type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:E
Last Name:VALDIVIA
Suffix:
Gender:M
Credentials:PT
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 1551
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34284-1551
Mailing Address - Country:US
Mailing Address - Phone:941-468-1660
Mailing Address - Fax:941-484-6024
Practice Address - Street 1:12355 SW COUNTY ROAD 769
Practice Address - Street 2:SUITE B
Practice Address - City:LAKE SUZY
Practice Address - State:FL
Practice Address - Zip Code:34269-5923
Practice Address - Country:US
Practice Address - Phone:941-468-1660
Practice Address - Fax:941-484-6024
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
001872584OtherHIGHMARK BCBS
FLY053NOtherBCBS
FLE4858Medicare ID - Type UnspecifiedOLD PROVIDER #
001872584OtherHIGHMARK BCBS
FLP00286873Medicare ID - Type UnspecifiedRR MEDICARE INDIVIDUAL #
FLDE3452Medicare ID - Type UnspecifiedRR MEDICARE GROUP #
FLE4858ZMedicare ID - Type UnspecifiedNEW PROVIDER #