Provider Demographics
NPI:1962509562
Name:VALDIVIA, MARIA DE LOS ANGELES (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:DE LOS ANGELES
Last Name:VALDIVIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 SW 1ST ST
Mailing Address - Street 2:320
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-2321
Mailing Address - Country:US
Mailing Address - Phone:305-644-0977
Mailing Address - Fax:305-644-0977
Practice Address - Street 1:1393 SW 1ST ST
Practice Address - Street 2:320
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-2321
Practice Address - Country:US
Practice Address - Phone:305-644-0977
Practice Address - Fax:305-644-0977
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38920208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065844800Medicaid
FL065844800Medicaid
E46770Medicare UPIN