Provider Demographics
NPI:1114699907
Name:URDANETA AQUI, JORGE ALBERTO (LM)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ALBERTO
Last Name:URDANETA AQUI
Suffix:
Gender:M
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3574 W 94TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2076
Mailing Address - Country:US
Mailing Address - Phone:786-340-5895
Mailing Address - Fax:
Practice Address - Street 1:10570 NW 27TH ST STE H102B
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-2104
Practice Address - Country:US
Practice Address - Phone:786-280-8061
Practice Address - Fax:786-280-8061
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW410176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife