Provider Demographics
NPI:1750742839
Name:OVIEDO, PURA
Entity type:Individual
Prefix:
First Name:PURA
Middle Name:
Last Name:OVIEDO
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 1:1815 PROSPECT AVE APT 3G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-6825
Mailing Address - Country:US
Mailing Address - Phone:347-259-1123
Mailing Address - Fax:
Practice Address - Street 1:1815 PROSPECT AVE APT 3G
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-6825
Practice Address - Country:US
Practice Address - Phone:347-259-1123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY536793907171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator