Basic Information
| Provider Information | |||||||||
| NPI: | 1407842024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TORRES-BERASTAIN | ||||||||
| FirstName: | IDELISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9582 W COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | OCOEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347616992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078963055 | ||||||||
| FaxNumber: | 4078261103 | ||||||||
| Practice Location | |||||||||
| Address1: | 9582 W COLONIAL DR | ||||||||
| Address2: | |||||||||
| City: | OCOEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347616992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078963055 | ||||||||
| FaxNumber: | 8261103866 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME94666 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3613069 | 01 | MA | AETNA/US HEALTHCARE | OTHER | 971091 | 01 | MD | NETWORK HEALTH | OTHER | 8992153 | 01 | MA | CIGNA | OTHER | 215875 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 90531 | 01 | MA | FALLON | OTHER | AA17289 | 01 | MA | HARVARD PILGRIM HEALTHCAR | OTHER | J26090 | 01 | MA | BLUE CROSS/BLUE SHIELD | OTHER | 30204323 | 01 | NH | NH MEDICAID | OTHER | 2003899 | 05 | MA | MEDICAID | P00197113 | 01 | MA | RAILROAD MEDICARE | OTHER | 01Y007670NH01 | 01 | NH | NH BLUE SHIELD | OTHER | 46644 | 01 | MA | HEALTHY START | OTHER | 2238547 | 01 | MA | FIRST HEALTH | OTHER |