Basic Information
| Provider Information | |||||||||
| NPI: | 1538455225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORONA RUIZ | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | MARIO | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORONA | ||||||||
| OtherFirstName: | JUAN | ||||||||
| OtherMiddleName: | MARIO | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2120 E JOHNSON AVE STE 106 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504946003 | ||||||||
| FaxNumber: | 8504946936 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 E JOHNSON AVE STE 106 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325146091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504946003 | ||||||||
| FaxNumber: | 8504946936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2011 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207T00000X | ME152543 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.