Provider Demographics
NPI:1346582087
Name:CIVERCHIA, LINDA LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:LINDA
Middle Name:LEE
Last Name:CIVERCHIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LINDA
Other - Middle Name:CIVERCHIA
Other - Last Name:BALENT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:333 LAS OLAS WAY APT 210
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2374
Mailing Address - Country:US
Mailing Address - Phone:954-235-3220
Mailing Address - Fax:954-523-5429
Practice Address - Street 1:333 LAS OLAS WAY 210
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2363
Practice Address - Country:US
Practice Address - Phone:954-235-3220
Practice Address - Fax:954-523-5429
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 39279174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 39279OtherMEDICAL LICENSE