Provider Demographics
NPI:1396723417
Name:NUNEZ, BORIS DALTON (MD)
Entity type:Individual
Prefix:DR
First Name:BORIS
Middle Name:DALTON
Last Name:NUNEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-3750
Mailing Address - Country:US
Mailing Address - Phone:863-679-7985
Mailing Address - Fax:863-679-1865
Practice Address - Street 1:320 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-3750
Practice Address - Country:US
Practice Address - Phone:863-679-7985
Practice Address - Fax:863-679-1865
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69460207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL378887300Medicaid
FL378887300Medicaid
FL27978YMedicare ID - Type Unspecified