Basic Information
Provider Information | |||||||||
NPI: | 1396974614 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANA | ||||||||
FirstName: | TED | ||||||||
MiddleName: | ROBERT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14750 NW 77TH CT STE 100 | ||||||||
Address2: |   | ||||||||
City: | MIAMI LAKES | ||||||||
State: | FL | ||||||||
PostalCode: | 330161507 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7867583165 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4450 E FLETCHER AVE STE D | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336134907 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136328861 | ||||||||
FaxNumber: | 8139774907 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2009 | ||||||||
LastUpdateDate: | 06/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS10551 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 2083P0500X | OS-009175-L | PA | N |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine | 2083P0500X | OS 10551 | FL | N |   | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
No ID Information.