Basic Information
Provider Information | |||||||||
NPI: | 1184887903 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEL CARPIO TENORIO | ||||||||
FirstName: | CRISTIAN | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEL CARPIO TENORIO | ||||||||
OtherFirstName: | CRISTIAN | ||||||||
OtherMiddleName: | RODOLFO | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1300 MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323084646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502160100 | ||||||||
FaxNumber: | 3522595731 | ||||||||
Practice Location | |||||||||
Address1: | 1300 MEDICAL DR | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323084646 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8502160100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2008 | ||||||||
LastUpdateDate: | 06/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME131679 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | 7100296920 | 05 | KY |   | MEDICAID |