Provider Demographics
NPI:1477791465
Name:DEL VALLE SERRANO, KARYMAR (MD)
Entity Type:Individual
Prefix:
First Name:KARYMAR
Middle Name:
Last Name:DEL VALLE SERRANO
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 1:619 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5808
Mailing Address - Country:US
Mailing Address - Phone:386-755-3016
Mailing Address - Fax:386-719-3622
Practice Address - Street 1:619 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5808
Practice Address - Country:US
Practice Address - Phone:386-755-3016
Practice Address - Fax:386-719-3622
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17446208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012467000Medicaid
FLACN553OtherSTATE LICENSE
FLCU181AOtherMEDICARE - PR
PR17446OtherSTATE LICENSE
FLHV698ZOtherMEDICARE - FL