1952667834 NPI number — CARLOS ALBERTO LISTA-ENSENAT MD PA

Table of content: DR. ANDREW DODSON BEATY M.D. (NPI 1891848271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952667834 NPI number — CARLOS ALBERTO LISTA-ENSENAT MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CARLOS ALBERTO LISTA-ENSENAT MD PA
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:
1952667834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12320 QUAIL ROOST DR
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:
33177-4930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
786-237-3070
Provider Business Mailing Address Fax Number:
786-430-8198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12320 QUAIL ROOST DR
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:
33177-4930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-237-3070
Provider Business Practice Location Address Fax Number:
786-430-8198
Provider Enumeration Date:
04/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LISTA-ENSENAT
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
786-237-3070

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME109021 , 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)





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