Provider Demographics
NPI:1689318693
Name:VELOZ HERNANDEZ, MIRTHA MARIA
Entity Type:Individual
Prefix:DR
First Name:MIRTHA
Middle Name:MARIA
Last Name:VELOZ HERNANDEZ
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 1:7005 N LOIS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-3158
Mailing Address - Country:US
Mailing Address - Phone:786-704-6218
Mailing Address - Fax:
Practice Address - Street 1:7005 N LOIS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3158
Practice Address - Country:US
Practice Address - Phone:786-704-6218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN26845122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program