Basic Information
| Provider Information | |||||||||
| NPI: | 1477791465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEL VALLE SERRANO | ||||||||
| FirstName: | KARYMAR | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867193622 | ||||||||
| Practice Location | |||||||||
| Address1: | 619 S MARION AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320255808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867553016 | ||||||||
| FaxNumber: | 3867193622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2009 | ||||||||
| LastUpdateDate: | 06/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 17446 | PR | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 012467000 | 05 | FL | MEDICAID | ACN553 | 01 | FL | STATE LICENSE | OTHER | CU181A | 01 | FL | MEDICARE - PR | OTHER | 17446 | 01 | PR | STATE LICENSE | OTHER | HV698Z | 01 | FL | MEDICARE - FL | OTHER |