Provider Demographics
NPI:1407087547
Name:GRADOS VALDERRAMA, FLOR DE MARIA (MD)
Entity Type:Individual
Prefix:
First Name:FLOR
Middle Name:DE MARIA
Last Name:GRADOS VALDERRAMA
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 1:2802 PARGOUD BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2802 PARGOUD BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2335
Practice Address - Country:US
Practice Address - Phone:305-766-9688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203138208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1802433Medicaid