1114319902 NPI number — DORILAS FOUNDATION CORPORATION

Table of content: LOUIS DANIEL NEISTADT MD (NPI 1194825455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114319902 NPI number — DORILAS FOUNDATION CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DORILAS FOUNDATION CORPORATION
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:
1114319902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3510 NW 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33311-6416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3510 NW 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33311-6416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-478-2041
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DORILAS
Authorized Official First Name:
FANUEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
954-478-2041

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  70734 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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