1255395620 NPI number — MARTIN R. CORREA MD

Table of content: MARTIN R. CORREA MD (NPI 1255395620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255395620 NPI number — MARTIN R. CORREA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORREA
Provider First Name:
MARTIN
Provider Middle Name:
R.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1255395620
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11880 SW 40TH ST
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33175-3584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-223-8808
Provider Business Mailing Address Fax Number:
305-223-8974

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1960 NE 47TH ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-7708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-772-3366
Provider Business Practice Location Address Fax Number:
954-489-9820
Provider Enumeration Date:
04/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  ME86090 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 265729500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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