Provider Demographics
NPI:1588782882
Name:MADIEDO, VIVIANA (PT)
Entity type:Individual
Prefix:MRS
First Name:VIVIANA
Middle Name:
Last Name:MADIEDO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20275 MONTEVERDI CIR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-6782
Mailing Address - Country:US
Mailing Address - Phone:561-451-9526
Mailing Address - Fax:561-883-2055
Practice Address - Street 1:20275 MONTEVERDI CIR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33498-6782
Practice Address - Country:US
Practice Address - Phone:561-451-9526
Practice Address - Fax:561-883-2055
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 11511225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU35952Medicare ID - Type UnspecifiedMCB - PHYSICAL THERAPIST