1497223341 NPI number — LISSETTE D CORTAZAR MDPA

Table of content: (NPI 1497223341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497223341 NPI number — LISSETTE D CORTAZAR MDPA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LISSETTE D CORTAZAR MDPA
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:
1497223341
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3661 S MIAMI
Provider Second Line Business Mailing Address:
SUITE 402
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33133-4330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-815-0055
Provider Business Mailing Address Fax Number:
347-493-3512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3661 S MIAMI AVE STE 402
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33133-4230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-815-0055
Provider Business Practice Location Address Fax Number:
347-493-3512
Provider Enumeration Date:
11/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
CORTAZAR
Authorized Official First Name:
LISSETTE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
786-205-4066

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 105998900 . 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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