Basic Information
| Provider Information | |||||||||
| NPI: | 1497775316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTIPORDA | ||||||||
| FirstName: | GLORIOSA | ||||||||
| MiddleName: | REYES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DELEON | ||||||||
| OtherFirstName: | GLORIOSA | ||||||||
| OtherMiddleName: | REYES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 120 KING ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322042410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9042821550 | ||||||||
| Practice Location | |||||||||
| Address1: | 8225 NORMANDY BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322216650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043788520 | ||||||||
| FaxNumber: | 9043788570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME47869 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.