Provider Demographics
NPI:1891285508
Name:URDANETA TORRES, ENDER ALFONSO (SA-C)
Entity Type:Individual
Prefix:
First Name:ENDER
Middle Name:ALFONSO
Last Name:URDANETA TORRES
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13840 TIMBERBROOKE DR APT 101
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824-6359
Mailing Address - Country:US
Mailing Address - Phone:407-690-7799
Mailing Address - Fax:
Practice Address - Street 1:13840 TIMBERBROOKE DR APT 101
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32824-6359
Practice Address - Country:US
Practice Address - Phone:407-690-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-179246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant