Provider Demographics
NPI:1689873200
Name:PIMENTEL VALDIVIA, RENAN (MD)
Entity Type:Individual
Prefix:
First Name:RENAN
Middle Name:
Last Name:PIMENTEL VALDIVIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 W UNDERWOOD ST
Mailing Address - Street 2:MP 80
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2008
Mailing Address - Country:US
Mailing Address - Phone:888-912-3648
Mailing Address - Fax:321-841-4085
Practice Address - Street 1:86 W UNDERWOOD ST
Practice Address - Street 2:MP 80
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2008
Practice Address - Country:US
Practice Address - Phone:888-912-3648
Practice Address - Fax:321-841-4085
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003425207R00000X, 208M00000X
FLME112583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102385934Medicaid
FLME112583OtherMEDICAL LICENSE
FL004727800Medicaid
NY03153555Medicaid
NY03153555Medicaid
NYJ400006960Medicare PIN