Provider Demographics
NPI:1962658351
Name:GIRALDO, IVAN MAURICIO (LMT)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:MAURICIO
Last Name:GIRALDO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2072 S MILITARY TRL
Mailing Address - Street 2:SUITE # 4
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-6419
Mailing Address - Country:US
Mailing Address - Phone:561-281-5522
Mailing Address - Fax:
Practice Address - Street 1:2072 S MILITARY TRL
Practice Address - Street 2:SUITE # 4
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-6419
Practice Address - Country:US
Practice Address - Phone:561-281-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA23533171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor