Provider Demographics
NPI:1598744914
Name:URDANETA, MAYRE
Entity Type:Individual
Prefix:
First Name:MAYRE
Middle Name:
Last Name:URDANETA
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 1:7320 NW 114TH AVE
Mailing Address - Street 2:APT 204
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-5588
Mailing Address - Country:US
Mailing Address - Phone:305-826-0606
Mailing Address - Fax:
Practice Address - Street 1:8060 NW 155TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-5883
Practice Address - Country:US
Practice Address - Phone:305-826-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73691174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42248Medicare ID - Type Unspecified
FL658621Medicare UPIN
FLG58621Medicare UPIN