Provider Demographics
NPI:1184992919
Name:FIALLO CORONADO, INGRID TATIANA (MD)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:TATIANA
Last Name:FIALLO CORONADO
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 1:9679 LAKE NONA VILLAGE PL STE 103
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7310
Mailing Address - Country:US
Mailing Address - Phone:407-826-1895
Mailing Address - Fax:321-203-4601
Practice Address - Street 1:9679 LAKE NONA VILLAGE PL STE 103
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7310
Practice Address - Country:US
Practice Address - Phone:407-826-1895
Practice Address - Fax:321-203-4601
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111064207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHA855YOtherMEDICARE