Provider Demographics
NPI:1750653259
Name:ANTONIO R. VIRSIDA, PH.D., P.A.
Entity Type:Organization
Organization Name:ANTONIO R. VIRSIDA, PH.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLGIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:R
Authorized Official - Last Name:VIRSIDA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-338-0902
Mailing Address - Street 1:370 CAMINO GARDENS BLVD
Mailing Address - Street 2:106
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5816
Mailing Address - Country:US
Mailing Address - Phone:561-338-0902
Mailing Address - Fax:
Practice Address - Street 1:370 CAMINO GARDENS BLVD
Practice Address - Street 2:106
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-5816
Practice Address - Country:US
Practice Address - Phone:561-338-0902
Practice Address - Fax:561-338-0433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY00003255103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75227Medicare PIN