Provider Demographics
NPI:1427409184
Name:CORDERO, JOSE MANUEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MANUEL
Last Name:CORDERO
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 1:400 GRAN BAHAMA BLVD
Mailing Address - Street 2:APT 10202
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-8322
Mailing Address - Country:US
Mailing Address - Phone:407-955-7027
Mailing Address - Fax:
Practice Address - Street 1:400 GRAN BAHAMA BLVD
Practice Address - Street 2:APT 10202
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-8322
Practice Address - Country:US
Practice Address - Phone:407-955-7027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC636433764610343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)