1902973464 NPI number — WEST DADE PEDIATRICS

Table of content: (NPI 1902973464)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902973464 NPI number — WEST DADE PEDIATRICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST DADE PEDIATRICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902973464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3220 SW 107TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33165-3606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-551-1195
Provider Business Mailing Address Fax Number:
305-551-1094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7100 W 20TH AVE
Provider Second Line Business Practice Location Address:
SUITE 411
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33016-1897
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-823-0901
Provider Business Practice Location Address Fax Number:
305-558-5304
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EGUSQUIZA
Authorized Official First Name:
JULIO
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENTIAL
Authorized Official Telephone Number:
305-551-1195

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 268809301 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 268809300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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