Provider Demographics
NPI:1699942821
Name:JATIVA, MARCELA (MD)
Entity type:Individual
Prefix:
First Name:MARCELA
Middle Name:
Last Name:JATIVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARCELA
Other - Middle Name:
Other - Last Name:JATIVA-CASTANEDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1356 STATE ROAD 60 E
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4322
Mailing Address - Country:US
Mailing Address - Phone:863-679-8888
Mailing Address - Fax:
Practice Address - Street 1:1356 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4322
Practice Address - Country:US
Practice Address - Phone:863-679-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109816208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003691200Medicaid
FL14CQ7Medicare PIN