Provider Demographics
NPI:1497775316
Name:ANTIPORDA, GLORIOSA REYES (MD)
Entity Type:Individual
Prefix:
First Name:GLORIOSA
Middle Name:REYES
Last Name:ANTIPORDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GLORIOSA
Other - Middle Name:REYES
Other - Last Name:DELEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:120 KING ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-2410
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-282-1550
Practice Address - Street 1:8225 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-6650
Practice Address - Country:US
Practice Address - Phone:904-378-8520
Practice Address - Fax:904-378-8570
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15433VMedicare ID - Type Unspecified
FLD52582Medicare UPIN