Provider Demographics
NPI:1407842024
Name:TORRES-BERASTAIN, IDELISA (MD)
Entity Type:Individual
Prefix:
First Name:IDELISA
Middle Name:
Last Name:TORRES-BERASTAIN
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 1:9582 W COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-6992
Mailing Address - Country:US
Mailing Address - Phone:407-896-3055
Mailing Address - Fax:407-826-1103
Practice Address - Street 1:9582 W COLONIAL DR
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-6992
Practice Address - Country:US
Practice Address - Phone:407-896-3055
Practice Address - Fax:826-110-3866
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME946662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3613069OtherAETNA/US HEALTHCARE
MD971091OtherNETWORK HEALTH
MA8992153OtherCIGNA
MA215875OtherTUFTS HEALTH PLAN
MA90531OtherFALLON
MAAA17289OtherHARVARD PILGRIM HEALTHCAR
MAJ26090OtherBLUE CROSS/BLUE SHIELD
NH30204323OtherNH MEDICAID
MA2003899Medicaid
MAP00197113OtherRAILROAD MEDICARE
NH01Y007670NH01OtherNH BLUE SHIELD
MA46644OtherHEALTHY START
MA2238547OtherFIRST HEALTH
MA2238547OtherFIRST HEALTH
MAJ26090OtherBLUE CROSS/BLUE SHIELD
MA2238547OtherFIRST HEALTH
MAA35322Medicare ID - Type UnspecifiedMEDICARE