Provider Demographics
NPI:1013473198
Name:PIEDRA, WALTHER MARTIN
Entity Type:Individual
Prefix:
First Name:WALTHER
Middle Name:MARTIN
Last Name:PIEDRA
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 1:5768 TAMARAC DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8058
Mailing Address - Country:US
Mailing Address - Phone:321-210-6175
Mailing Address - Fax:
Practice Address - Street 1:5768 TAMARAC DR
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8058
Practice Address - Country:US
Practice Address - Phone:321-210-6175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP362893672490172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP362893672490OtherDRIVER LINCENSE