1700851458 NPI number — MIRIAM MERCEDES MALDONADO LM

Table of content: MIRIAM MERCEDES MALDONADO LM (NPI 1700851458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700851458 NPI number — MIRIAM MERCEDES MALDONADO LM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALDONADO
Provider First Name:
MIRIAM
Provider Middle Name:
MERCEDES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LM
Provider Gender Code:
F

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:
1700851458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 557203
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:
33255-7203
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-234-9056
Provider Business Mailing Address Fax Number:
813-365-3074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10540 NW 26TH STREET
Provider Second Line Business Practice Location Address:
BLDG G UNIT 108
Provider Business Practice Location Address City Name:
DORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33172-2104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-607-2229
Provider Business Practice Location Address Fax Number:
813-365-3074
Provider Enumeration Date:
02/17/2006

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: 374J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 176B00000X , with the licence number: MW165 , 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: 014406800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 340536200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 014406800 . 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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