Basic Information
Provider Information | |||||||||
NPI: | 1093193526 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONTALVO | ||||||||
FirstName: | ARA | ||||||||
MiddleName: | JAMASBI | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JAMASBI | ||||||||
OtherFirstName: | ARA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2147 | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339022147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2394241500 | ||||||||
FaxNumber: | 2394241423 | ||||||||
Practice Location | |||||||||
Address1: | 9981 S HEALTHPARK DR | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339083618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2393436260 | ||||||||
FaxNumber: | 2393436259 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/17/2015 | ||||||||
LastUpdateDate: | 11/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME140960 | FL | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207PP0204X | ME140960 | FL | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
ID | Type | State | Issuer | Description | 103085500 | 05 | FL |   | MEDICAID |