Provider Demographics
NPI:1598138299
Name:CUSTODIO, MARGARITA
Entity Type:Individual
Prefix:
First Name:MARGARITA
Middle Name:
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 E IDLEWILD AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6456
Mailing Address - Country:US
Mailing Address - Phone:352-702-7483
Mailing Address - Fax:
Practice Address - Street 1:236 E IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6456
Practice Address - Country:US
Practice Address - Phone:352-702-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL603613Medicaid