Provider Demographics
NPI:1417943242
Name:CORONADO, EPHRAIN ENRIQUE (MD)
Entity Type:Individual
Prefix:MR
First Name:EPHRAIN
Middle Name:ENRIQUE
Last Name:CORONADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:EFRAIN
Other - Middle Name:ENRIQUE
Other - Last Name:CORONADO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1150 S. SEMORAN BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-1424
Mailing Address - Country:US
Mailing Address - Phone:407-482-5253
Mailing Address - Fax:407-482-5254
Practice Address - Street 1:1150 S. SEMORAN BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1424
Practice Address - Country:US
Practice Address - Phone:407-482-5253
Practice Address - Fax:407-482-5254
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 652292085R0202X
FLME652292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005544400Medicaid
FL005544400Medicaid
FL42711Medicare PIN