Basic Information
| Provider Information | |||||||||
| NPI: | 1508851577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LA PUERTA | ||||||||
| FirstName: | MANUEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12222 | ||||||||
| Address2: | ATTN: CREDENTIAL DEPT | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392748200 | ||||||||
| FaxNumber: | 2392783350 | ||||||||
| Practice Location | |||||||||
| Address1: | 6420 W NEWBERRY RD | ||||||||
| Address2: | EAST WING, SUITE 100 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523323900 | ||||||||
| FaxNumber: | 3523325009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0000X | ME67324 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology | 207RX0202X | ME67324 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 261472300 | 05 | FL | MEDICAID |