Provider Demographics
NPI:1346738341
Name:MADERA, JAVIER ANTONIO
Entity Type:Individual
Prefix:
First Name:JAVIER
Middle Name:ANTONIO
Last Name:MADERA
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 1:613 LEGACY PARK DR
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-2406
Mailing Address - Country:US
Mailing Address - Phone:407-953-3468
Mailing Address - Fax:
Practice Address - Street 1:1002 N SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3531
Practice Address - Country:US
Practice Address - Phone:407-275-8939
Practice Address - Fax:407-282-3674
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101YA0400XMedicaid