Provider Demographics
NPI:1821180779
Name:TUPAS LEVITAN, HERRIET VILLANEAL (MD)
Entity type:Individual
Prefix:
First Name:HERRIET
Middle Name:VILLANEAL
Last Name:TUPAS LEVITAN
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:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32790
Mailing Address - Country:US
Mailing Address - Phone:407-645-4441
Mailing Address - Fax:407-645-3242
Practice Address - Street 1:1925 MIZELL AVENUE
Practice Address - Street 2:SUITE 301
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792
Practice Address - Country:US
Practice Address - Phone:407-645-4441
Practice Address - Fax:407-645-3242
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047659500Medicaid
FL047659500Medicaid
E61724Medicare UPIN