Provider Demographics
NPI:1811383953
Name:MALDONADO, ALBERTO
Entity Type:Individual
Prefix:
First Name:ALBERTO
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-5909
Mailing Address - Country:US
Mailing Address - Phone:614-589-9552
Mailing Address - Fax:
Practice Address - Street 1:254 VISTA DR
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-5909
Practice Address - Country:US
Practice Address - Phone:614-589-9552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2021-09-08
Deactivation Date:2018-11-23
Deactivation Code:
Reactivation Date:2020-04-09
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0061743Medicaid