Provider Demographics
NPI:1023431863
Name:QUINTERO, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:QUINTERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11616 LAKE UNDERHILL RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-4463
Mailing Address - Country:US
Mailing Address - Phone:407-482-7788
Mailing Address - Fax:321-235-8328
Practice Address - Street 1:11616 LAKE UNDERHILL RD
Practice Address - Street 2:SUITE 215
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4463
Practice Address - Country:US
Practice Address - Phone:407-482-7788
Practice Address - Fax:321-235-8328
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME85171174400000X
FLME54751174400000X
FLME113836174400000X
FLME105350174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAD890OtherMEDICARE
FL000962800Medicaid