Provider Demographics
NPI:1407044480
Name:LEGRA DELGADO, VIANKA (MD)
Entity Type:Individual
Prefix:
First Name:VIANKA
Middle Name:
Last Name:LEGRA DELGADO
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 1:3218 W HORATIO ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3028
Mailing Address - Country:US
Mailing Address - Phone:813-600-9981
Mailing Address - Fax:866-441-4463
Practice Address - Street 1:7756 PALM RIVER RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-4215
Practice Address - Country:US
Practice Address - Phone:813-626-0066
Practice Address - Fax:866-441-4463
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117947207R00000X
FLME101871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000250100Medicaid
FLBH229ZMedicare PIN