Provider Demographics
NPI:1649273186
Name:SEGUROLA, ROMUALDO JOSE JR (MD)
Entity type:Individual
Prefix:
First Name:ROMUALDO
Middle Name:JOSE
Last Name:SEGUROLA
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21097 NE 27TH CT STE 350
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1234
Mailing Address - Country:US
Mailing Address - Phone:786-428-1059
Mailing Address - Fax:786-428-1062
Practice Address - Street 1:21097 NE 27TH CT STE 350
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1234
Practice Address - Country:US
Practice Address - Phone:786-428-1059
Practice Address - Fax:786-428-1062
Is Sole Proprietor?:No
Enumeration Date:2005-05-29
Last Update Date:2024-04-10
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
FLME80950208G00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269329100Medicaid
37866ZMedicare ID - Type Unspecified
FL269329100Medicaid