Basic Information
| Provider Information | |||||||||
| NPI: | 1063499119 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | URDANETA | ||||||||
| FirstName: | JAVIER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S HARBOUR ISLAND BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336025925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273223439 | ||||||||
| FaxNumber: | 8009287449 | ||||||||
| Practice Location | |||||||||
| Address1: | 5414 DEEP LAKE RD STE 1104 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327655243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079869850 | ||||||||
| FaxNumber: | 8443886186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 08/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME68802 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 378071600 | 05 | FL | MEDICAID |