1396016044 NPI number — DR. JUAN OSVALDO PAGAN M.D.

Table of content: DR. JUAN OSVALDO PAGAN M.D. (NPI 1396016044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396016044 NPI number — DR. JUAN OSVALDO PAGAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PAGAN
Provider First Name:
JUAN
Provider Middle Name:
OSVALDO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1396016044
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
759 NW 22ND AVE
Provider Second Line Business Mailing Address:
201
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33125-3365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-541-5245
Provider Business Mailing Address Fax Number:
305-541-5246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9299 SW 152ND ST
Provider Second Line Business Practice Location Address:
201
Provider Business Practice Location Address City Name:
PALMETTO BAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33157-1737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-233-0137
Provider Business Practice Location Address Fax Number:
305-252-8160
Provider Enumeration Date:
01/25/2012

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: 2084P0804X , with the licence number:  15332 , 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: 105814500 . 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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