Provider Demographics
NPI:1003291600
Name:SAN BLAS VALDES, JUAN ANTONIO SR
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:ANTONIO
Last Name:SAN BLAS VALDES
Suffix:SR
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 1:100 SW 110TH AVE APT 125
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1255
Mailing Address - Country:US
Mailing Address - Phone:305-560-0853
Mailing Address - Fax:
Practice Address - Street 1:100 SW 110TH AVE APT 125
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1255
Practice Address - Country:US
Practice Address - Phone:305-560-0853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13-664282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital