Basic Information
| Provider Information | |||||||||
| NPI: | 1790748671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASANOVA NATER | ||||||||
| FirstName: | ANGEL | ||||||||
| MiddleName: | LUIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443660 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 AVENUE F NE | ||||||||
| Address2: | EMERGENCY DEPT | ||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632931121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 01/24/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME97079 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M3960 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | M3960 | 01 | TX | MEDICAL LIC | OTHER | 277930700 | 05 | FL | MEDICAID | BC 7695919 | 01 | DEA | OTHER | ME97079 | 01 | FL | MEDICAL LIC | OTHER |