Provider Demographics
NPI:1255429882
Name:SIERRA, VIRGILIO (MOTR/L)
Entity type:Individual
Prefix:MR
First Name:VIRGILIO
Middle Name:
Last Name:SIERRA
Suffix:
Gender:M
Credentials:MOTR/L
Other - Prefix:
Other - First Name:VIRGIL
Other - Middle Name:
Other - Last Name:SIERRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:1526 WHITE HALL DR
Mailing Address - Street 2:#406
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-6678
Mailing Address - Country:US
Mailing Address - Phone:954-382-2178
Mailing Address - Fax:
Practice Address - Street 1:3157 N UNIVERSITY DR
Practice Address - Street 2:SUITE #103
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-2258
Practice Address - Country:US
Practice Address - Phone:954-442-9422
Practice Address - Fax:954-442-9150
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT11800225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8903255Medicaid