1467483073 NPI number — NESTOR F DE LA CRUZ MUNOZ JR. M.D.

Table of content: NESTOR F DE LA CRUZ MUNOZ JR. M.D. (NPI 1467483073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467483073 NPI number — NESTOR F DE LA CRUZ MUNOZ JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE LA CRUZ MUNOZ
Provider First Name:
NESTOR
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1467483073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1611 NW 12TH 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:
33136-1005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-585-1288
Provider Business Mailing Address Fax Number:
305-856-4301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3650 NW 82ND AVE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
DORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33166-6658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-856-4385
Provider Business Practice Location Address Fax Number:
305-856-4301
Provider Enumeration Date:
07/05/2006

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: 208600000X , with the licence number:  ME71258 , 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: 001451600 . 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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