Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | ME96207 | FL |
NPI | 1194824243 |
---|---|
Provider Name | Salvador Orlando Montenegro |
First Address | Lakeland, FL 33805-3019 |
Second Address | Lakeland, FL 33805-3019 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2006 |
Last Update Date | 18/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I38592 | (02) |