Provider Demographics
NPI:1689712754
Name:URDANIVIA, JENRY (MA42629)
Entity Type:Individual
Prefix:MR
First Name:JENRY
Middle Name:
Last Name:URDANIVIA
Suffix:
Gender:M
Credentials:MA42629
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2980 SW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-2118
Mailing Address - Country:US
Mailing Address - Phone:786-271-1581
Mailing Address - Fax:
Practice Address - Street 1:2980 SW 26TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-2118
Practice Address - Country:US
Practice Address - Phone:786-271-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 42629171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor