Provider Demographics
NPI:1528214202
Name:ALTAMIRANDA, ALEX A (DPT)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:A
Last Name:ALTAMIRANDA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 91770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13330 USF LAUREL DR
Practice Address - Street 2:MDC 62
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6601
Practice Address - Country:US
Practice Address - Phone:813-974-8613
Practice Address - Fax:813-974-8614
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5776OtherLICENSE
FL001588000Medicaid
FLY01W2OtherBLUE CROSS BLUE SHIELD
FLY01W2OtherBLUE CROSS BLUE SHIELD