Provider Demographics
NPI:1063048585
Name:MONTALVAN, JUDITH ROSALYN
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ROSALYN
Last Name:MONTALVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 NE 214TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-1317
Mailing Address - Country:US
Mailing Address - Phone:305-610-5229
Mailing Address - Fax:
Practice Address - Street 1:2011 NE 60TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2127
Practice Address - Country:US
Practice Address - Phone:954-830-9508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other