1902973464 NPI number — WEST DADE PEDIATRICS

Table of Contents

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:
03/27/2025
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:
7150 W 20TH AVE
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33016-5531
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:
305-823-0901

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: 268809300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 268809301 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 268809300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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